Relationship of Sleep Duration With All‐Cause Mortality and Cardiovascular Events: A Systematic Review and Dose‐Response Meta‐Analysis of Prospective Cohort Studies

Abstract

Background
Effects of extreme sleep duration on risk of mortality and cardiovascular outcomes remain controversial. We aimed to quantify the dose‐response relationships of sleep duration with risk of all‐cause mortality, total cardiovascular disease, coronary heart disease, and stroke.

Methods and Results
PubMed and Embase were systematically searched for prospective cohort studies published before December 1, 2016, that examined the associations between sleep duration and at least 1 of the 4 outcomes in generally healthy populations. U‐shaped associations were indicated between sleep duration and risk of all outcomes, with the lowest risk observed for ≈7‐hour sleep duration per day, which was varied little by sex. For all‐cause mortality, when sleep duration was <7 hours per day, the pooled relative risk (RR) was 1.06 (95% CI, 1.04–1.07) per 1‐hour reduction; when sleep duration was >7 hours per day, the pooled RR was 1.13 (95% CI, 1.11–1.15) per 1‐hour increment. For total cardiovascular disease, the pooled RR was 1.06 (95% CI, 1.03–1.08) per 1‐hour reduction and 1.12 (95% CI, 1.08–1.16) per 1‐hour increment of sleep duration. For coronary heart disease, the pooled RR was 1.07 (95% CI, 1.03–1.12) per 1‐hour reduction and 1.05 (95% CI, 1.00–1.10) per 1‐hour increment of sleep duration. For stroke, the pooled RR was 1.05 (95% CI, 1.01–1.09) per 1‐hour reduction and 1.18 (95% CI, 1.14–1.21) per 1‐hour increment of sleep duration.

Conclusions
Our findings indicate that both short and long sleep duration is associated with an increased risk of all‐cause mortality and cardiovascular events.

Full text

Relationship of Sleep Duration With All-Cause Mortality and
Cardiovascular Events: A Systematic Review and Dose-Response
Meta-Analysis of Prospective Cohort Studies
Jiawei Yin, MD; Xiaoling Jin, MD; Zhilei Shan, PhD; Shuzhen Li, MD; Hao Huang, MD; Peiyun Li, MD; Xiaobo Peng, MD; Zhao Peng, MD;
Kaifeng Yu, MD; Wei Bao, PhD; Wei Yang, PhD; Xiaoyi Chen, MD, PhD; Liegang Liu, MD, PhD
Background-—Effects of extreme sleep duration on risk of mortality and cardiovascular outcomes remain controversial. We aimed
to quantify the dose-response relationships of sleep duration with risk of all-cause mortality, total cardiovascular disease, coronary
heart disease, and stroke.
Methods and Results-—PubMed and Embase were systematically searched for prospective cohort studies published before
December 1, 2016, that examined the associations between sleep duration and at least 1 of the 4 outcomes in generally healthy
populations. U-shaped associations were indicated between sleep duration and risk of all outcomes, with the lowest risk observed
for 7-hour sleep duration per day, which was varied little by sex. For all-cause mortality, when sleep duration was <7 hours per
day, the pooled relative risk (RR) was 1.06 (95% CI, 1.04–1.07) per 1-hour reduction; when sleep duration was >7 hours per day,
the pooled RR was 1.13 (95% CI, 1.11–1.15) per 1-hour increment. For total cardiovascular disease, the pooled RR was 1.06 (95%
CI, 1.03–1.08) per 1-hour reduction and 1.12 (95% CI, 1.08–1.16) per 1-hour increment of sleep duration. For coronary heart
disease, the pooled RR was 1.07 (95% CI, 1.03–1.12) per 1-hour reduction and 1.05 (95% CI, 1.00–1.10) per 1-hour increment of
sleep duration. For stroke, the pooled RR was 1.05 (95% CI, 1.01–1.09) per 1-hour reduction and 1.18 (95% CI, 1.14–1.21) per
1-hour increment of sleep duration.
Conclusions-—Our findings indicate that both short and long sleep duration is associated with an increased risk of all-cause
mortality and cardiovascular events. (J Am Heart Assoc. 2017;6:e005947. DOI: 10.1161/JAHA.117.005947.)
Key Words: all-cause death •cardiovascular disease •coronary heart disease •meta-analysis •sleep •stroke
According to the report of World Congress of Cardiology
and Cardiovascular Health in 2016, cardiovascular
diseases (CVDs) are the leading cause of death globally, with
an estimate of >17 million deaths from total CVD. Of these
deaths, >7 million were due to coronary heart disease (CHD)
and >6 million were due to stroke. In <10 years, the
premature deaths from CVDs could rise by a third.
1
To
reduce the risk of premature death from noncommunicable
diseases by 25% by 2025, as a global target of the World
Health Organization,
2
it is imperative to identify modifiable
lifestyle factors associated with lower occurrence of CVDs.
Sleep is a complex set of brain processes that supports
several physiological needs.
3
Increased attention has been
paid to understanding the extent of sleep duration problems
at the population level and their associated negative effects
on various health outcomes, such as metabolic syndrome,
From the Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety (J.Y., X.J., Z.S., S.L., H.H., P.L., X.P., Z.P., K.Y., W.Y., L.L.) and
MOE Key Lab of Environment and Health, School of Public Health (J.Y., X.J., Z.S., S.L., H.H., P.L., X.P., Z.P., K.Y., W.Y., L.L.), Tongji Medical College, Huazhong University
of Science & Technology, Wuhan, China; Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (Z.S.); Department of Epidemiology, College
of Public Health, University of Iowa, Iowa City, IA (W.B.); School of Public Health, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou, China (X.C.).
Accompanying Data S1, Tables S1 through S12 and Figures S1 through S13 are available at http://jaha.ahajournals.org/content/6/9/e005947/DC1/embed/
inline-supplementary-material-1.pdf
Correspondence to: Liegang Liu, MD, PhD, Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of
Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road,
Wuhan 430030, China. E-mail: lgliu@mails.tjmu.edu.cn
Xiaoyi Chen, MD, PhD, School of Public Health, Guangzhou Medical University, Xinzao, Panyu District, Guangzhou 511436, China. E-mail: wwchenxy1@163.com
Received March 9, 2017; accepted June 1, 2017.
ª2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons
Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for
commercial purposes.
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diabetes mellitus, and cancer.
4–6
Previous publications sug-
gest that the prevalence of short sleep duration (defined as
<7 hours) may have gradually increased over past decades,
whereas the prevalence of long sleep duration (defined as
≥9 hours) shows an opposite trend.
7
In recent years, increasing evidence has suggested that
extreme sleep duration is associated with the risk of
mortality and cardiovascular outcomes; however, the results
are not entirely consistent. Although several studies found
that sleep duration that was either too short or too long was
associated with increased risk of all-cause mortality and
cardiovascular events,
8–13
reverse associations were
observed in other populations.
14,15
In addition, uncertainty
exists about the dose-response relationship between sleep
duration and risk of the adverse outcomes because different
quantitative categories of sleep duration were used in
previous studies.
8,16–18
Two meta-analyses reported the
association between sleep duration and all-cause mortality
with dose-response analysis, but the results were inconsis-
tent.
19,20
A previous meta-analysis published before 2011
reported the association between sleep duration and
cardiovascular events
21
; however, without a dose-response
analysis, it remains unknown how many hours of habitual
sleep are associated with the lowest risk of cardiovascular
events. Since 2011, many more studies have been published
and the number of prospective studies has nearly tripled,
which allows quantitative analysis of the associations.
Consequently, we conducted a comprehensive dose-
response meta-analysis of prospective studies in generally
healthy populations to determine the overall shape of the
relationships and quantitative estimates between sleep
duration and risk of all-cause mortality, total CVD, CHD,
and stroke.
Methods
Search Strategy
This study was conducted in accordance with the MOOSE
(Meta-Analysis of Observational Studies in Epidemiology)
guidelines.
22
We performed a literature search (up to
December 1, 2016) of PubMed and Embase for prospective
studies examining the association between sleep duration and
risk of all-cause mortality and selected cardiovascular
outcomes (Data S1). In addition, we reviewed references
from relevant original articles and review articles to identify
further pertinent studies. Only articles published in the English
language were considered.
Study Selection
Studies were included if they satisfied the following criteria:
The study design was a prospective cohort study; the
exposure of interest was sleep duration; the outcome was
all-cause mortality, CVD, CHD, or stroke; and the investigators
reported relative risk (RR), hazard ratio, or odds ratio (OR) with
95% confidence intervals (CIs) for at least 3 quantitative
categories of sleep duration. Given that primary prevention of
CVD was the main focus of this work (rather than secondary
prevention), we excluded studies if participants were not
recruited from a generally healthy population (eg, those with
diabetes mellitus or under regular dialysis therapy). In
addition, we excluded reviews, editorials, nonhuman studies,
and letters without sufficient data. Multiple reports from the
same cohort study were reviewed, and only articles with the
longest follow-up for identical outcomes were included. If
insufficient data were presented in the longer follow-up study,
we included the shorter follow-up data. Study selection was
conducted in 2 stages: an initial screening of titles and
abstracts to identify potentially relevant articles, followed by
screening of the full-length articles. Two investigators (J.W.Y.
and S.Z.L.) independently screened all studies by title or
abstract and then by a full-text evaluation. Any discrepancy
between the 2 authors was solved by discussion with the
senior investigator (X.L.J.).
Data Extraction and Quality Assessment
The extraction of data included authors, year of publication,
study name, study location, years of follow-up, sample size
(number of participants and incident cases), participant
characteristics (age and sex), measurement method of sleep
duration (questionnaire and interview), types of sleep duration
(24-hour sleep, nighttime sleep), covariates adjusted in the
multivariable analysis, and effect size (RR, hazard ratio, OR),
with 95% CIs for all categories of sleep duration. When studies
had several adjustment models, we extracted those that
Clinical Perspective
What Is New?
•Uncertainty exists regarding the dose-response relationship
between sleep duration and the risk of all-cause mortality
and cardiovascular events.
•In our systematic review and meta-analysis, sleep duration
that was either too short or too long was associated with
higher risk of all-cause mortality and cardiovascular events,
with the lowest risk at sleep duration of 7 hours per day.
What Are the Clinical Implications?
•The U-shaped associations between sleep duration and
adverse outcomes have clinical relevance with respect to
recommendations for adequate sleep duration in routine
clinical care as well as explicit suggestions for primary
prevention in public health settings.
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reflected the maximum extent of adjustment for potentially
confounding variables.
Quality assessment was performed according to the
Newcastle–Ottawa Quality Assessment Scale (NOS).
23
Scores
ranged from 0 to 9 points, with higher scores indicating higher
study quality. We considered NOS scores of 0 to 3, 4 to 6, and
7 to 9 as low, medium, and high quality, respectively.
To evaluate potential dose-response relationships, we
further extracted numbers of cases, numbers of participants,
and median sleep duration in each category. If the numbers of
participants and cases were not provided, the corresponding
authors were contacted for the data.
Data Synthesis and Analysis
In this meta-analysis, the RR was used as the common measure
of association across studies, and the hazard ratio was deemed
equivalent to RR.
24
If necessary, the OR was transformed into
RR according to this formula: RR=OR/[(1P
0
)+(P
0
9OR)],
where P
0
is the incidence of the outcome of interest in the
nonexposed group.
25
Any results stratified by sex were treated
as 2 separate reports. Those articles reporting >1 outcome (eg,
all-cause mortality and total CVD) were also treated as separate
reports and included in corresponding analyses. If the number
of cases in each category was not available in 1 study and the
authors did not give their reply, we used the method by
Bekkering et al to provide approximate data.
26
We recognized that sleeping 7 to 8 hours per night was
treated as the reference category in the majority of studies.
When the reference category was not 7 to 8 hours, we used the
method proposed by Hamling and colleagues to convert risk
estimates.
27
We calculated pooled RRs and 95% CIs for the
extreme categories of sleep duration versus the reference
category of sleep duration. In addition, the reports with at least
3 quantitative categories of short or long sleep duration were
included in dose-response analyses. Potential nonlinear dose-
response relationships between sleep duration and all-cause
mortality and cardiovascular events were examined by using
restricted cubic splines model with 4 knots at percentiles 5%,
35%, 65%, and 95% of the distribution.
28,29
We assigned the
median or mean sleep duration in each category to the
corresponding RR for each study. If the mean or median
duration per category was not reported, the midpoint of the
upper and lower boundaries in each category was assigned.
When the shortest or the longest category was open-ended, we
assumed that the open-ended interval length had the same
length as the adjacent interval. The dose-response curves are
shown in the nonlinear figures. The RR estimates in the tables
were based on the nonlinear figures but show RRs for selected
sleep-duration values. If a nonlinear shape association was
observed, we treated the slope as 2 piecewise and conducted
dose-response analyses using the method by Greenland and
Longnecker to calculate pooled RR and 95% CIs for 1-hour
increment or decrement compared with the reference category
in sleep duration.
30
We used a Pvalue for curve linearity or
nonlinearity to assess the difference between the linear and
nonlinear models to test for nonlinearity.
29
All pooled outcome
measures were determined using random-effects models,
described by DerSimonian and Laird,
31
to provide more
conservative results than fixed-effects models.
The heterogeneity among studies was estimated by the
Cochran Q test (P≤0.1 to be indicative of statistically significant
heterogeneity) and I
2
statistic.
32
We conducted subgroup and
metaregression analyses stratified by sex, study location, number
of participants, number of cases, duration of follow-up, sleep
assessment, sleep duration type, study quality, incidence or
mortality (only in total CVD, stroke and CHD), and adjustment for
confounders to investigate potential sources of heterogeneity
between subgroups. Moreover, stratified analyses were per-
formed to evaluate the influences of selected study and
participant characteristics on the results. Publication bias was
assessed by inspection of the funnel plots for asymmetry withthe
Egger test
33
and Begg test.
34
The Duval and Tweedie
35
nonpara-
metric trim-and-fill method was used to further assess the
possible effect of publication bias. Additional sensitivity analyses
were performed by omitting 1 study at each time to test the
robustness of the results and the influence of an individual study
on heterogeneity.
36
All statistical analyses were performed with
Stata version 12 (StataCorp LP), and all tests were 2-sided with a
significance level of 0.05 unless otherwise noted.
Results
Literature Search
Figure 1 shows the results of literature research and selec-
tion. We identified 836 articles from PubMed and 837 articles
from Embase before December 1, 2016. After exclusion of
duplicates and studies that did not fulfill the inclusion criteria,
101 remaining articles seemed to be relevant for this meta-
analysis. After evaluating the full texts of these 101 publica-
tions and counting 1 study obtained by hand searching, the
final meta-analysis included 67 articles with 141 independent
reports. Among these 67 articles, 43 articles with 57 reports
provided statistical effects relevant to the meta-analyses on
all-cause mortality, 26 articles with 37 reports on total CVD,
22 articles with 27 reports on CHD, and 16 articles with 20
reports on stroke (Data S1).
Study Characteristics
A summary of the study characteristics is shown in Tables S1
through S4. The sample sizes ranged from 724 to 1 116 936,
with a total of 3 582 016 participants, including 241 107
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cases of all-cause mortality, 58 919 cases of total CVD, 22 511
cases of CHD, and 15 476 cases of stroke. The follow-up
periods ranged from 2.3 to 34 years. Among these 67 articles,
most were conducted in Europe (n=22), the United States
(n=16), and Asia (n=27); the others were done in Australia
(n=2). Sleep duration was measured by self-report question-
naires in 48 studies and by interview in 19 studies. The majority
of the included studies had high quality, as indicated by the NOS
Figure 1. Flowchart of article selection. CHD indicates coronary heart disease; CVD,
cardiovascular disease.
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score, and the mean study quality scores were 6.9 for all-cause
mortality, 7.0 for CVD, 7.0 for CHD, and 7.1 for stroke out of a
maximum of 9 points (Tables S5 through S8).
Sleep Duration and Risk of All-Cause Mortality
In total, 57 reports were included in the analysis of all-cause
mortality and extreme sleep duration. The pooled RR of the
shortest and longest sleep duration versus reference sleep
duration was 1.13 (95% CI, 1.09–1.17), with low to moderate
heterogeneity (I
2
=37.5%, P<0.01), and 1.35 (95% CI, 1.29–
1.41), with high heterogeneity (I
2
=76.2%, P<0.01), respec-
tively (Table 1, Figure S1).
Reports with at least 3 quantitative categories of short or
long sleep duration were included in dose-response analysis.
When using a restricted cubic splines model, we observed a
U-shape curvilinear association with the lowest risk of all-
cause mortality at a sleep duration of about 7 hours per day
(P<0.01 for nonlinearity; Figure 2A). Both short and long sleep
duration was associated with an increased risk of all-cause
mortality. Table 2 shows the RR estimates for selected sleep
duration values, which were derived from the nonlinear
figures. In the linear trend analyses for short sleep, no
evidence of nonlinear association between short sleep
duration and all-cause mortality was found (P=0.12), and
the pooled RR for all-cause mortality was 1.06 (95% CI, 1.04–
1.07) per 1-hour reduction of sleep duration, with moderate to
high heterogeneity (I
2
=55.5%, P<0.01; Figure 3A).
8–13,18,37–53
The heterogeneity was reduced when we excluded 2
reports
9,38
(I
2
=13.0%, P=0.26), but the association was not
substantially altered (pooled RR: 1.06; 95% CI, 1.05–1.07).
For long sleep, nonlinear association between long sleep
duration and all-cause mortality was found (P=0.02), and the
pooled RR for all-cause mortality was 1.13 (95% CI, 1.11–
1.15) per 1-hour increment of sleep duration, with high
heterogeneity (I
2
=76.5%, P<0.01) (Figure 3B).* The
heterogeneity seemed to be mainly generated by 8
reports,
8,13,40,42,44,45,53,56
and when these were all excluded,
the association still remained similar (RR: 1.12; 95% CI, 1.10–
1.13) with low heterogeneity (I
2
=21.7%, P=0.15).
Sleep Duration and Risk of Total CVD
Overall, 37 reports were included in the analysis of total CVD
and extreme sleep duration. A U-shaped association was
observed with the lowest risk of total CVD at a sleep duration
of 7 hours per day (P<0.01 for nonlinearity; Figure 2B,
Table 2). Both short and long sleep duration was associated
with an increased risk of total CVD.
For short sleep, the pooled RR of the shortest sleep
duration versus the reference sleep duration was 1.14 (95%
CI, 1.09–1.20), with low to moderate heterogeneity (I
2
=31.1%,
P=0.04; Table 1, Figure S2). We found no evidence of
nonlinear association between short sleep duration and total
CVD (P=0.19), and the pooled RR was 1.06 (95% CI, 1.03–
1.08) per 1-hour reduction of sleep duration, with moderate
heterogeneity (I
2
=52.0%, P<0.01; Figure 4A).
†
The hetero-
geneity was reduced when we excluded 1 report
9
(I
2
=24.8%,
P=0.63), and the association remained similar (pooled RR:
1.04; 95% CI, 1.02–1.06).
For long sleep, the pooled RR of the longest sleep duration
versus the reference sleep duration was 1.36 (95% CI, 1.26–
1.48), with high heterogeneity (I
2
=71.2%, P<0.01; Table 1,
Figure S2). A nonlinear association between long sleep
duration and total CVD was found (P=0.02), and the pooled
RR was 1.12 (95% CI, 1.08–1.16) per 1-hour increment of
sleep duration, with high heterogeneity (I
2
=75.3%, P<0.01;
Figure 4B).
‡
The heterogeneity seemed to be generated
mainly by 4 reports, and when those were all excluded, the
association not substantially altered (RR: 1.13; 95% CI, 1.11–
1.16) with low heterogeneity (I
2
=14.6%, P=0.28).
Table 1. Associations of Sleep Duration With All-Cause Mortality, Total CVD, CHD, and Stroke
n
Shortest vs Reference Longest vs Reference
RR* (95% CI) I
2
PValue
†
RR* (95% CI) I
2
PValue
†
All-cause mortality 57 1.13 (1.10–1.17) 37.5 <0.01 1.35 (1.29–1.41) 76.2 <0.01
Total CVD 37 1.14 (1.09–1.20) 31.1 0.04 1.36 (1.26–1.48) 71.2 <0.01
CHD 27 1.22 (1.13–1.31) 39.6 0.02 1.21 (1.12–1.30) 37.4 0.03
Stroke 20 1.09 (0.99–1.19) 40.6 0.03 1.45 (1.30–1.62) 63.5 <0.01
CHD indicates coronary heart disease; CI, confidence interval; CVD, cardiovascular disease; RR, relative risk.
*RR favors the analyses of shortest and longest vs reference sleep duration.
†
Pfor heterogeneity.
*References 8–13, 18, 37, 39–42, 44–48, 50–59.
†
References 8–13, 38, 44, 48–50, 52, 60–63.
‡
References 8–13, 15, 44, 48–50, 52, 54–56, 61, 62.
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Sleep Duration and Risk of CHD
In total, 27 reports were included in the analysis of CHD and
extreme sleep duration. A U-shaped association was
observed, with the lowest risk of CHD at a sleep duration of
7 hours per day (P<0.01 for nonlinearity; Figure 2C,
Table 2). Both short and long sleep duration was associated
with an increased risk of CHD.
For short sleep, the pooled RR of the shortest sleep
duration versus the reference sleep duration was 1.22 (95%
CI, 1.13–1.31), with low to moderate heterogeneity
(I
2
=39.6%, P=0.02; Table 1, Figure S3). In the linear trend
analyses for short sleep, a nonlinear association was noted
between short sleep duration and CHD (P=0.02), and the
pooled RR was 1.07 (95% CI, 1.03–1.12) per 1-hour
reduction of sleep duration, with moderate to high hetero-
geneity (I
2
=59.3%, P<0.01) (Figure 5A).
§
The heterogeneity
was reduced when we excluded 2 reports
13,66
(I
2
=23.2%,
P=0.19), and the association remained similar (pooled RR:
1.04; 95% CI, 1.01–1.08).
For long sleep, the pooled RR of the longest sleep duration
versus the reference sleep duration was 1.21 (95% CI, 1.12–
1.30), with low to moderate heterogeneity (I
2
=37.4%, P=0.03;
Table 1, Figure S3). A nonlinear association was noted
between long sleep duration and CHD (P<0.01), and the
pooled RR was 1.05 (95% CI, 1.00–1.10) per 1-hour increment
of sleep duration, with moderate to high heterogeneity
(I
2
=64.2%, P<0.01; Figure 5B).
k
The heterogeneity was
reduced when we excluded 2 reports
15,66
(I
2
=4.0%, P=0.41),
and the association remained similar (pooled RR: 1.06; 95%
CI, 1.03–1.09).
Sleep Duration and Risk of Stroke
Twenty reports were included in the analysis of stroke and
extreme sleep duration. An approximate U-shape curvilinear
association was observed, with the lowest risk of stroke at a
Figure 2. Nonlinear dose-response analyses of sleep duration and risk of all-cause mortality (A), total CVD (B), CHD (C), and stroke (D). CHD
indicates coronary heart disease; CVD, cardiovascular disease.
§
References 11, 13, 16, 37, 43, 49, 60, 61, 63–68.
k
References 11, 13, 15, 37, 49, 54, 61, 64, 66–69.
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sleep duration of 6 to 7 hours per day (P<0.01 for
nonlinearity; Figure 2D, Table 2). Both short and long sleep
duration was associated with an increased risk of stroke.
For short sleep, the pooled RR of the shortest sleep
duration versus the reference sleep duration was 1.09 (95%
CI, 0.99–1.19), with low to moderate heterogeneity (I
2
=40.6%,
P=0.03; Table 1, Figure S4). In the linear trend analyses for
short sleep, we found no evidence of nonlinear association
between short sleep duration and stroke (P=0.23), and the
pooled RR for stroke was 1.05 (95% CI, 1.01–1.09) per 1-hour
reduction of sleep duration, with no significant heterogeneity
(I
2
=0.0%, P=0.55) (Figure 6A).
¶
For long sleep, the pooled RR of the longest sleep duration
versus the reference sleep duration was 1.45 (95% CI, 1.30–
1.62), with moderate to high heterogeneity (I
2
=63.5%,
P<0.01; Table 1, Figure S4). No evidence of nonlinear dose-
response relationship was detected (P=0.13), and the pooled
RR for stroke was 1.18 (95% CI, 1.14–1.21) per 1-hour
increment of sleep duration, with low heterogeneity (I
2
=4.9%,
P=0.40; Figure 6B).
#
Publication Bias
For the shortest or longest sleep duration versus the
reference sleep duration, the publication bias was found
between longest sleep duration and total CVD. The Begg rank
correlation test indicated no publication bias (P=0.41), but the
Egger linear regression test indicated possible publication
bias for the association (P=0.01). We used the trim-and-fill
method to recalculate our pooled risk estimate, and 13
missing studies were imputed to produce a symmetrical
funnel plot (Figure S5). The analysis suggested that the
imputed risk estimate was 1.22 (95% CI, 1.12–1.32), which is
slightly decreased in risk but still identical to our original risk
estimate. No significant publication bias was observed for
other outcomes.
For the dose-response analysis, we analyzed the publica-
tion bias of short sleep duration and all-cause mortality and
found that the Begg rank correlation test indicated no
publication bias (P=0.59), but the Egger linear regression
test indicated possible publication bias for the association
(P=0.01). The trim-and-fill method was used to recalculate our
pooled risk estimate, and 10 missing studies were imputed to
produce a symmetrical funnel plot (Figure S6). The analysis
suggested that the imputed risk estimate was 1.04 (95% CI,
1.03–1.06), which is identical to our original risk estimate. No
significant publication bias was observed for other outcomes.
Subgroup, Metaregression, and Sensitivity
Analyses
Tables S9 through S12 shows the different subgroup analyses
of studies on all-cause mortality, total CVD, CHD, and stroke.
To explore potential sources of heterogeneity between
subgroups, we carried out metaregression analyses of
prespecified moderator variables. In the analyses of all-cause
mortality, the association between sleep duration and risk
were not substantially changed in most subgroups. There was
indication of heterogeneity (P=0.01) when we stratified
studies by sleep duration type, and the pooled RRs for 1-hour
increment in long sleep duration were 1.16 (95% CI,
1.13–1.18; n=24) and 1.11 (95% CI, 1.10–1.13; n=13) for
nighttime and 24-hour sleep duration, respectively. In the
nonlinear dose-response analysis, slight variations in the risk
Table 2. Association Between Sleep Duration and All-Cause Mortality, Total CVD, CHD and Stroke From Non-Linear Dose-
Response Analysis
Sleep Duration All-Cause Mortality (n=40*) Total CVD (n=26*) CHD (n=20*) Stroke (n=17*)
3 h 1.12 (1.10–1.14) 1.14 (1.09–1.19)  
4 h 1.08 (1.06–1.09) 1.09 (1.06–1.13) 1.16 (1.09–1.23) 1.05 (0.96–1.15)
5 h 1.04 (1.03–1.05) 1.05 (1.03–1.08) 1.11 (1.06–1.16) 1.02 (0.96–1.08)
6 h 1.01 (1.00–1.01) 1.02 (1.00–1.03) 1.05 (1.03–1.08) 0.99 (0.96–1.03)
7 h 1.00 1.00 1.00 1.00
8 h 1.04 (1.04–1.05) 1.03 (1.02–1.05) 1.01 (0.99–1.03) 1.08 (1.06–1.11)
9 h 1.15 (1.14–1.16) 1.16 (1.13–1.19) 1.14 (1.08–1.20) 1.30 (1.24–1.37)
10 h 1.32 (1.29–1.35) 1.37 (1.29–1.45) 1.34 (1.20–1.50) 1.64 (1.47–1.82)
11 h 1.53 (1.47–1.59)   
CHD indicates coronary heart disease; CVD, cardiovascular disease.
*n denotes number of risk estimates.
¶
References 8, 11, 13, 17, 49, 60, 63, 64, 70, 71.
#
References 8, 11, 13, 17, 49, 54, 64, 70–73.
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estimates from the nonlinear dose-response analyses were
observed (Figure S7).
In the analyses of total CVD, the associations between
sleep duration and risk were not substantially changed in
most subgroups. Heterogeneity was indicated (P<0.01) when
we stratified studies by incidence or mortality, and the pooled
RRs for 1-hour increment in long sleep duration were 1.00
(95% CI, 0.97–1.03; n=6) and 1.15 (95% CI, 1.12–1.16; n=16)
for incidence and mortality, respectively. In the nonlinear
analysis restricted to studies that reported the incidence of
total CVD, there was no significantly increased risk of total
CVD at the extreme sleep duration, whereas the U-shaped
association was more pronounced among the studies that
reported mortality of total CVD (Figure S8). There was
evidence of heterogeneity by study location in the linear dose-
response analysis of all participants (P=0.01), and the lowest
RR was observed at 8-hour sleep duration in Europe
(Figure S9).
In the analyses of CHD, the pooled RRs for 1-hour
increment in long sleep duration were 0.89 (95% CI, 0.82–
0.97; n=4) for Europe with indication of heterogeneity
(P=0.02) by study location, which was inconsistent with other
results. There was indication of heterogeneity (P=0.02) when
we stratified studies by incidence or mortality, and the pooled
RRs for 1-hour increment in long sleep duration were 1.01
(95% CI, 0.97–1.07; n=12) and 1.13 (95% CI, 1.06–1.20; n=7)
for incidence and mortality, respectively. There was no
significantly increased risk of CHD at the extreme sleep
duration; the U-shaped association was more pronounced
among the studies that reported mortality of CHD
(Figure S10).
In the analyses of stroke, the association between sleep
duration and risk was not substantially changed in most
subgroups. There was indication of heterogeneity (P=0.01)
when we stratified studies by duration of follow-up, with a
weaker association among studies with increasing durations
of follow-up (Figure S11).
To further confirm the robustness of the results, the dose-
response analyses were repeated using a fixed-effects model;
the pooled estimates were consistent for short and long sleep
duration in relation to risk of all-cause mortality and
cardiovascular events. Sensitivity analyses omitting 1 study
at a time did not substantially alter the pooled results for both
short and long sleep duration and all-cause mortality, total
Figure 3. The forest plots between sleep duration (per hour) and risk of all-cause mortality for short sleep (A) and long sleep (B). CI indicates
confidence interval.
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CVD, and CHD. For stroke, when we excluded 1 study,
72
there
was a statistically significant association in the analysis of the
shortest versus reference sleep duration, and short sleep
duration was associated with an increased risk of stroke
(Figures S12 and S13).
Discussion
To our knowledge, the present work is the largest and most
comprehensive study on the association of sleep duration
with all-cause mortality and cardiovascular events. Our study
demonstrated U-shaped associations between sleep duration
and risk of all-cause mortality, total CVD, CHD, and stroke,
with the lowest risk observed with 7 hours of sleep duration.
Sleep duration that was too short or too long was significantly
associated with elevated risks of all-cause mortality, total
CVD, CHD, and stroke. Compared with 7 hours per day, a
1-hour decrease was associated with 6%, 6%, 7%, and 5%
increased risk of all-cause mortality, total CVD, CHD, and
stroke, respectively, and a 1-hour increase in sleep duration
was associated with 13%, 12%, 5%, and 18% increased risk,
respectively.
To date, association between extreme sleep duration and
increased risk of all-cause mortality was reported previously
in studies with large sample sizes and high quality,
8–13
which
was consistent with our results. Heslop and colleagues,
14
however, analyzed data from a workplace-based study of
Scottish men and women who were followed over a 25-year
period and found that long sleep was associated with
decreased all-cause mortality in men. But this study reported
RRs with only 3 quantitative categories of sleep duration;
meanwhile, long sleep duration was defined as >8 hours,
which may result in inaccurate assessment of extreme long
sleep. Recently, 2 systematic reviews,
19,20
both exploring
the association between all-cause mortality and sleep
duration (separate analysis of 24-hour sleep duration and
nighttime sleep duration), observed markedly inconsistent
results for short sleep duration. Results from Liu et al
20
showed that short sleep duration was not associated with
higher risk of all-cause mortality in nighttime sleep duration.
Nevertheless, results from Shen et al
19
showed that for both
24-hour and nighttime sleep duration, U-shaped relationships
were found, and the lowest risk of all-cause mortality was
observed with 7 hours per day of sleep duration, in line with
our results; however, in the study by Shen et al, 1 cohort
study
74
was included twice in analysis. Moreover, the linear
associations on the 2 sides of 7-hour sleep duration were
not detected.
Figure 4. The forest plots between sleep duration (per hour) and risk of total cardiovascular disease for short sleep (A) and long sleep (B). CI
indicates confidence interval.
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Some studies have found an adverse association between
extreme sleep duration and cardiovascular events. In our
study, both short and long sleep duration was indicated to be
associated with an increased risk of total CVD, which was
inconsistent with a previous systematic review
21
in 2011. In
that study, short duration of sleep was not significantly
associated with a greater risk of total CVD, possibly because
of limited included studies. Nineteen prospective cohort
studies (26 reports) have been published since 2011 and
were included in our study to describe the dose-response
relationship between sleep duration and risk of total CVD. To
our surprise, the findings from our subgroup analyses showed
a decreased risk of CHD with long sleep duration in Europe,
which should be interpreted carefully, given limited included
studies. The association disappeared when we omitted the
MOGEN study.
15
This research showed that long sleep
duration tended to be protective for CHD; however, U-shaped
associations were observed in the subgroup analysis of sleep
quality in participants with available data. Notably, the
proportion of women among long sleepers was significantly
higher than that of men in the baseline population, whereas
higher mortality rates and risks of CHD were observed in men
than in women in published studies.
75
This may lead to the
different result. Moreover, our subgroup analyses for total
CVD and CHD showed indications of heterogeneity when we
stratified studies by incidence and mortality. The U-shaped
association was more pronounced among the studies that
reported the mortality of total CVD or CHD compared with
those that reported the incidence of total CVD or CHD. The
association between cardiovascular events and sleep duration
might be enhanced in the process through which patients
tended to go from the occurrence of disease to death. It may
also indicate that appropriate sleep duration is particularly
important for delaying death among those people with chronic
CVDs, and this needs to be identified further in additional
studies. In our study, the adverse effect of short sleep for
stroke was not observed in the shortest sleep duration versus
reference analysis, whereas short sleep duration was asso-
ciated with a higher risk of stroke in the dose-response
analysis. By sensitivity analysis, we found that 1 study
72
had
an obvious influence on the result of the shortest sleep
duration versus reference analysis. The research indicated
that a decreased risk of mortality from stroke was associated
with short duration of sleep. Nonetheless, the small number
of participants with short sleep duration limited the ability to
separately analyze the effect of ≤5 and 6 hours of sleep, and
the study was not included in the dose-response analysis
because it had too few categories of short sleep. After
omitting the studies with <3 categories of short sleep, the
pooled RR of the shortest versus reference sleep duration was
Figure 5. The forest plots between sleep duration (per hour) and risk of coronary heart disease for short sleep (A) and long sleep (B). CI
indicates confidence interval.
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1.16 (95% CI, 1.03–1.31), which was in line with the dose-
response analysis.
Sex and age are important variables in risk of death and
CVDs; this was generally accepted. In light of previous
studies, the association between sleep duration and mortal-
ity
8,57,58
and cardiovascular events
16,67
varies by sex; how-
ever, in our subgroup analyses, extreme sleep durations were
significantly associated with elevated risks of all-cause
mortality, total CVD, CHD, and stroke in both men and
women. Our metaregression analyses further demonstrated
that there was no potential source of heterogeneity from the
sex variable; therefore, a sex difference in the association of
sleep duration with death and CVDs must be interpreted with
caution. In addition, several studies found a stronger
U-shaped association between sleep duration and CVDs in
older adults compared with younger adults (cutoff at age
65 years).
10,16
Nevertheless, the result in a study including
60 000 Chinese participants (cutoff at age 60 years) was not
entirely consistent.
66
Considering that the age range of the
study population varied widely and the length of follow-up was
different among the included studies, we did not conduct
subgroup analyses stratified by age. Further studies concen-
trated on sleep duration and adverse outcomes among
different age groups are warranted in the future.
Short and long sleep duration may share some relevant
mechanisms in relation to all-cause mortality and
cardiovascular events. As elucidated in published articles,
extreme sleep duration on both sides was associated with
elevated C-reactive protein.
76
As widely accepted, however,
distinctive mechanisms with their own characteristics may
operate at either end of the distribution of sleep duration.
77
Several potential mechanisms may contribute to the
relationship between short sleep duration and adverse
outcomes. First, sleep restriction during the night has multiple
effects on endocrine and metabolic function such as
decreases of testosterone
78
and melatonin secretion,
79
which
also may be implicated with mortality or cardiovascular
events.
80,81
Second, observational studies also found that
short duration of sleep was associated with vascular damage,
such as coronary artery calcification.
82
Third, short duration of
sleep was associated with reduced levels of leptin and
elevated levels of ghrelin.
83,84
The serum leptin and ghrelin
levels are independent predictors of cardiovascular morbidity
and mortality.
85,86
Finally, individuals with sleep deprivation,
especially shift workers, have irregular sleep schedules,
resulting in circadian misalignment, which may aggravate
CVD in humans.
87
The potential mechanisms underlying the association
between long sleep duration and adverse outcomes are
considered more speculative. Some insisted that the
elevated risk of long sleep duration most likely represented
the confounding effects of subhealthy status or
Figure 6. The forest plots between sleep duration (per hour) and risk of stroke for short sleep (A) and long sleep (B). CI indicates confidence
interval.
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uncontrolled chronic illness, such as obstructive sleep
apnea, a known cause of increased need for sleep and an
identified risk factor for mortality and cardiovascular
events.
88
As mentioned, changes in inflammatory markers
and vascular health come with long sleep duration, as
shown by new evidence in recent years. First, long sleep
duration may be associated with an increased risk of
atherosclerosis.
82
Second, excessive time in bed has been
linked to increased sleep fragmentation,
89
which was
considered to be associated with more severe arterioloscle-
rosis and subcortical macroscopic infarcts. These were
independent risk factors of CVD and several medical
comorbidities.
90
Third, long sleep duration has been linked
with feelings of fatigue and lethargy, which in turn would
cause sleep extension. These states may fail to provide
sufficient restoration against stress and disease and then
lead to increased mortality.
91
Finally, long duration of sleep
was associated with depressive symptoms, low socioeco-
nomic status, unemployment, low household income, low
level of education, and other risk factors for mortality and
cardiovascular events.
92
Further experimental studies are
warranted to explore the potential effects of sleep exten-
sion on health outcomes.
This meta-analysis has several strengths. All studies
included in our meta-analysis used a prospective design,
thus the differential misclassification of sleep duration
attributable to recall bias was minimized. The majority of
the included studies had relatively high quality. Moreover, we
investigated a dose-response relationship between sleep
duration and the outcomes, allowing us to examine the
shape of this possible association. Linear and nonlinear
relationships were also tested to assess the dose-response
relationship.
Several limitations of our study should also be acknowl-
edged. First, nearly all studies relied on sleep duration that
was self-reported by questionnaire or interview; 1 study
93
provided the RRs between all-cause mortality and both
subjective and objective sleep duration, but no substantial
difference was observed. Meanwhile, in the big data era,
the widespread availability and acceptance of electronic
wearable devices, such as consumer-level activity monitors,
may allow accurate, reliable, and scalable objective sleep-
duration assessment in large epidemiological studies.
94
Second, sleep duration is a dynamic biological process. A
single measure of exposure may not fully capture the
sustained effects of sleep duration over time when related
to long-term disease incidence. One included study
95
addressed this issue by measuring changes in sleep
duration twice, several years apart, and found that stable
short and stable long sleep was associated with a
significantly increased risk of mortality; moreover, moving
to either shorter of longer sleep from average sleep was
also associated with increased mortality. This finding was in
line with our result that appropriate sleep duration was
important for the delay or prevention of premature
mortality. Third, we cannot rule out the possibility of
residual or unmeasured confounding, even though we have
taken into consideration major confounding factors by using
adjusted risk estimates from multivariate models from each
contributing study. Finally, sleep quality affected by factors
like sleep apnea is an independent predictor of risk of
adverse outcomes
96
but was not assessed in our study.
Despite the limitations, at this stage, results from prospec-
tive cohort studies are still the best evidence available to
assess the longitudinal effect of sleep duration on all-cause
mortality and cardiovascular events.
Conclusions
In summary, our dose-response meta-analysis of prospective
studies provides further evidence that sleep duration that is
either too short or too long is associated with higher risk of
all-cause mortality and cardiovascular events, with the lowest
risk with 7 hours per day of sleep duration. Longer term
randomized controlled trials are needed to establish causality
and to elucidate the underlying mechanisms.
Author Contributions
Yin, Shan, Chen, and Liu conceived the study. Yin searched
the databases, checked them according to the eligible criteria
and exclusion criteria, extracted and analyzed the data, and
wrote the draft of the article. S.Z. Li and Jin helped extract
quantitative data from some articles and contributed to
writing, reviewing, or revising the article. Huang, P.Y. Li, Shan,
Bao, Yang, X.B. Peng, Z. Peng and Yu critically reviewed and
revised for important intellectual content. Shan and Bao
provided advice on meta-analysis methodology and con-
tributed to reviewing, or revising the article. Liu is the
guarantor and had full access to all the data and takes
responsibility for the integrity of the data and the accuracy of
the data analysis.
Sources of Funding
This work was funded by the National Natural Science
Foundation of China (NSFC 81472978), the National Science
and Technology Support Program (2012BAI02B02) and China
Postdoctoral Science Foundation (2016M602314). Integrated
Innovative Team for Major Human Diseases Program of Tongji
Medical College, HUST. The funders had no role in study
design, data collection and analysis, decision to publish, or
preparation of the article.
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Disclosures
None.
References
1. World Heart Federation. World congress of cardiology & cardiovascular
health 2016. Available at: www.world-heart-federation.org/resources/world-
congress-cardiology-cardiovascular-health-2016/. Accessed December 1,
2016.
2. World Health Organization. Global action plan for the prevention and control of
NCDS 2013–2020. Available at: www.Who.Int/nmh/publications/ncd-action-
plan/en/. Accessed December 1, 2016.
3. Kirszenblat L, van Swinderen B. The yin and yang of sleep and attention.
Trends Neurosci. 2015;38:776–786.
4. St-Onge MP, Grandner MA, Brown D, Conroy MB, Jean-Louis G, Coons M, Bhatt
DL. Sleep duration and quality: impact on lifestyle behaviors and car-
diometabolic health: a scientific statement from the American Heart
Association. Circulation. 2016;134:e367–e386.
5. Shan Z, Ma H, Xie M, Yan P, Guo Y, Bao W, Rong Y, Jackson CL, Hu FB, Liu L.
Sleep duration and risk of type 2 diabetes: a meta-analysis of prospective
studies. Diabetes Care. 2015;38:529–537.
6. Qin Y, Zhou Y, Zhang X, Wei X, He J. Sleep duration and breast cancer risk: a
meta-analysis of observational studies. Int J Cancer. 2014;134:1166–1173.
7. Jean-Louis G, Williams NJ, Sarpong D, Pandey A, Youngstedt S, Zizi F,
Ogedegbe G. Associations between inadequate sleep and obesity in the US
adult population: analysis of the national health interview survey (1977–2009).
BMC Public Health. 2014;14:290.
8. Cai H, Shu XO, Xiang YB, Yang G, Li H, Ji BT, Gao J, Gao YT, Zheng W. Sleep
duration and mortality: a prospective study of 113 138 middle-aged and
elderly Chinese men and women. Sleep. 2015;38:529–536.
9. Bellavia A, Akerstedt T, Bottai M, Wolk A, Orsini N. Sleep duration and survival
percentiles across categories of physical activity. Am J Epidemiol.
2014;179:484–491.
10. Yeo Y, Ma SH, Park SK, Chang SH, Shin HR, Kang D, Yoo KY. A prospective
cohort study on the relationship of sleep duration with all-cause and disease-
specific mortality in the Korean Multi-Center Cancer Cohort Study. J Prev Med
Public Health. 2013;46:271–281.
11. Kim Y, Wilkens LR, Schembre SM, Henderson BE, Kolonel LN, Goodman MT.
Insufficient and excessive amounts of sleep increase the risk of premature
death from cardiovascular and other diseases: the Multiethnic Cohort Study.
Prev Med. 2013;57:377–385.
12. Kronholm E, Laatikainen T, Peltonen M, Sippola R, Partonen T. Self-reported
sleep duration, all-cause mortality, cardiovascular mortality and morbidity in
Finland. Sleep Med. 2011;12:215–221.
13. Ikehara S, Iso H, Date C, Kikuchi S, Watanabe Y, Wada Y, Inaba Y, Tamakoshi
A. Association of sleep duration with mortality from cardiovascular disease
and other causes for Japanese men and women: the JACC study. Sleep.
2009;32:295–301.
14. Heslop P, Smith GD, Metcalfe C, Macleod J, Hart C. Sleep duration and
mortality: the effect of short or long sleep duration on cardiovascular and all-
cause mortality in working men and women. Sleep Med. 2002;3:305–314.
15. Hoevenaar-Blom MP, Spijkerman AM, Kromhout D, van den Berg JF, Verschuren
WM. Sleep duration and sleep quality in relation to 12-year cardiovascular
disease incidence: the MORGEN study. Sleep. 2011;34:1487–1492.
16. Strand LB, Tsai MK, Gunnell D, Janszky I, Wen CP, Chang SS. Self-reported
sleep duration and coronary heart disease mortality: a large cohort study of
400,000 Taiwanese adults. Int J Cardiol. 2016;207:246–251.
17. Helbig AK, Stockl D, Heier M, Ladwig KH, Meisinger C. Symptoms of insomnia
and sleep duration and their association with incident strokes: findings from
the population-based MONICA/KORA Augsburg cohort study. PLoS One.
2015;10:e0134480.
18. Hall MH, Smagula SF, Boudreau RM, Ayonayon HN, Goldman SE, Harris TB,
Naydeck BL, Rubin SM, Samuelsson L, Satterfield S, Stone KL, Visser M,
Newman AB. Association between sleep duration and mortality is mediated by
markers of inflammation and health in older adults: the Health, Aging and Body
Composition Study. Sleep. 2015;38:189–195.
19. Shen X, Wu Y, Zhang D. Nighttime sleep duration, 24-hour sleep duration and
risk of all-cause mortality among adults: a meta-analysis of prospective cohort
studies. Sci Rep. 2016;6:21480.
20. Liu TZ, Xu C, Rota M, Cai H, Zhang C, Shi MJ, Yuan RX, Weng H, Meng XY,
Kwong JS, Sun X. Sleep duration and risk of all-cause mortality: a flexible, non-
linear, meta-regression of 40 prospective cohort studies. Sleep Med Rev.
2017;32:28–36.
21. Cappuccio FP, Cooper D, D’Elia L, Strazzullo P, Miller MA. Sleep duration
predicts cardiovascular outcomes: a systematic review and meta-analysis of
prospective studies. Eur Heart J. 2011;32:1484–1492.
22. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D,
Becker BJ, Sipe TA, Thacker SB. Meta-analysis of observational studies in
epidemiology: a proposal for reporting. Meta-analysis of Observational Studies
in Epidemiology (MOOSE) Group. JAMA. 2000;283:2008–2012.
23. Wells GS, Shea B, O’Connell D, Robertson J, Peterson J, Welch V, Losos M,
Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of
nonrandomized studies in meta-analyses. Available at: www.ohri.ca/progra
ms/clinical_epidemiology/oxford.asp. Accessed December 1, 2016.
24. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of
Interventions Version 5.1.0. The cochrane collaboration; 2011. Available at:
www.Cochrane-handbook.Org. Accessed December 1, 2016.
25. Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio
in cohort studies of common outcomes. JAMA. 1998;280:1690–1691.
26. Bekkering GE, Harris RJ, Thomas S, Mayer AM, Beynon R, Ness AR, Harbord
RM, Bain C, Smith GD, Sterne JA. How much of the data published in
observational studies of the association between diet and prostate or bladder
cancer is usable for meta-analysis? Am J Epidemiol. 2008;167:1017–1026.
27. Hamling J, Lee P, Weitkunat R, Ambuhl M. Facilitating meta-analyses by
deriving relative effect and precision estimates for alternative comparisons
from a set of estimates presented by exposure level or disease category. Stat
Med. 2008;27:954–970.
28. Jackson D, White IR, Thompson SG. Extending DerSimonian and Laird’s
methodology to perform multivariate random effects meta-analyses. Stat Med.
2010;29:1282–1297.
29. Orsini N, Li R, Wolk A, Khudyakov P, Spiegelman D. Meta-analysis for linear
and nonlinear dose-response relations: examples, an evaluation of approx-
imations, and software. Am J Epidemiol. 2012;175:66–73.
30. Greenland S, Longnecker MP. Methods for trend estimation from summarized
dose-response data, with applications to meta-analysis. Am J Epidemiol.
1992;135:1301–1309.
31. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials.
1986;7:177–188.
32. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in
meta-analyses. BMJ. 2003;327:557–560.
33. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis
detected by a simple, graphical test. BMJ. 1997;315:629–634.
34. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for
publication bias. Biometrics. 1994;50:1088–1101.
35. Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing
and adjusting for publication bias in meta-analysis. Biometrics. 2000;56:455–
463.
36. Wallace BC, Schmid CH, Lau J, Trikalinos TA. Meta-analyst: software for meta-
analysis of binary, continuous and diagnostic data. BMC Med Res Methodol.
2009;9:80.
37. Wang X, Liu X, Song Q, Wu S. Sleep duration and risk of myocardial infarction
and all-cause death in a Chinese population: the Kailuan study. Sleep Med.
2016;19:13–16.
38. Xiao Q, Keadle SK, Hollenbeck AR, Matthews CE. Sleep duration and total and
cause-specific mortality in a large US cohort: interrelationships with physical
activity, sedentary behavior, and body mass index. Am J Epidemiol.
2014;180:997–1006.
39. Rod NH, Kumari M, Lange T, Kivimaki M, Shipley M, Ferrie J. The joint effect of
sleep duration and disturbed sleep on cause-specific mortality: results from
the Whitehall II cohort study. PLoS One. 2014;9:e91965.
40. Magee CA, Holliday EG, Attia J, Kritharides L, Banks E. Investigation of the
relationship between sleep duration, all-cause mortality, and preexisting
disease. Sleep Med. 2013;14:591–596.
41. Li Y, Sato Y, Yamaguchi N. Potential biochemical pathways for the relationship
between sleep duration and mortality. Sleep Med. 2013;14:98–104.
42. Jung KI, Song CH, Ancoli-Israel S, Barrett-Connor E. Gender differences in
nighttime sleep and daytime napping as predictors of mortality in older adults:
the Rancho Bernardo study. Sleep Med. 2013;14:12–19.
43. Hale L, Parente V, Dowd JB, Sands M, Berger JS, Song Y, Martin LW, Allison
MA. Fibrinogen may mediate the association between long sleep duration and
coronary heart disease. J Sleep Res.2013;22:305–314.
44. Chen HC,Su TP, Chou P. A nine-yearfollow-upstudy of sleep patterns and mortality
in community-dwelling older adults in Taiwan. Sleep. 2013;36:1187–1198.
45. Qiu L, Sautter J, Liu Y, Gu D. Age and gender differences in linkages of sleep
with subsequent mortality and health among very old Chinese. Sleep Med.
2011;12:1008–1017.
DOI: 10.1161/JAHA.117.005947 Journal of the American Heart Association 13
Sleep Duration and Cardiovascular Events Yin et al
SYSTEMATIC REVIEW AND META-ANALYSIS
by guest on September 15, 2017http://jaha.ahajournals.org/Downloaded from

46. Castro-Costa E, Dewey ME, Ferri CP, Uchoa E, Firmo JO, Rocha FL, Prince M,
Lima-Costa MF, Stewart R. Association between sleep duration and all-cause
mortality in old age: 9-year follow-up of the Bambui Cohort Study, Brazil. J
Sleep Res. 2011;20:303–310.
47. Mesas AE, Lopez-Garcia E, Leon-Munoz LM, Guallar-Castillon P, Rodriguez-
Artalejo F. Sleep duration and mortality according to health status in older
adults. J Am Geriatr Soc. 2010;58:1870–1877.
48. Chien KL, Chen PC, Hsu HC, Su TC, Sung FC, Chen MF, Lee YT. Habitual sleep
duration and insomnia and the risk of cardiovascular events and all-cause
death: report from a community-based cohort. Sleep. 2010;33:177–184.
49. Amagai Y, Ishikawa S, Gotoh T, Kayaba K, Nakamura Y, Kajii E. Sleep duration
and incidence of cardiovascular events in a Japanese population: the Jichi
Medical School cohort study. J Epidemiol. 2010;20:106–110.
50. Suzuki E, Yorifuji T, Ueshima K, Takao S, Sugiyama M, Ohta T, Ishikawa-Takata
K, Doi H. Sleep duration, sleep quality and cardiovascular disease mortality
among the elderly: a population-based cohort study. Prev Med. 2009;49:135–
141.
51. Gangwisch JE, Heymsfield SB, Boden-Albala B, Buijs RM, Kreier F, Opler MG,
Pickering TG, Rundle AG, Zammit GK, Malaspina D. Sleep duration associated
with mortality in elderly, but not middle-aged, adults in a large US sample.
Sleep. 2008;31:1087–1096.
52. Patel SR, Ayas NT, Malhotra MR, White DP, Schernhammer ES, Speizer FE,
Stampfer MJ, Hu FB. A prospective study of sleep duration and mortality risk in
women. Sleep. 2004;27:440–444.
53. Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR. Mortality
associated with sleep duration and insomnia. Arch Gen Psychiatry.
2002;59:131–136.
54. Kakizaki M, Kuriyama S, Nakaya N, Sone T, Nagai M, Sugawara Y, Hozawa A,
Fukudo S, Tsuji I. Long sleep duration and cause-specific mortality according
to physical function and self-rated health: the Ohsaki Cohort Study. J Sleep
Res. 2013;22:209–216.
55. Stone KL, Ewing SK, Ancoli-Israel S, Ensrud KE, Redline S, Bauer DC, Cauley JA,
Hillier TA, Cummings SR. Self-reported sleep and nap habits and risk of
mortality in a large cohort of older women. J Am Geriatr Soc. 2009;57:604–
611.
56. Lan TY, Lan TH, Wen CP, Lin YH, Chuang YL. Nighttime sleep, Chinese
afternoon nap, and mortality in the elderly. Sleep. 2007;30:1105–1110.
57. Amagai Y, Ishikawa S, Gotoh T, Doi Y, Kayaba K, Nakamura Y, Kajii E. Sleep
duration and mortality in Japan: the Jichi Medical School cohort study. J
Epidemiol. 2004;14:124–128.
58. Kojima M, Wakai K, Kawamura T, Tamakoshi A, Aoki R, Lin Y, Nakayama T,
Horibe H, Aoki N, Ohno Y. Sleep patterns and total mortality: a 12-year follow-
up study in Japan. J Epidemiol. 2000;10:87–93.
59. Gale C, Martyn C. Larks and owls and health, wealth, and wisdom. BMJ.
1998;317:1675–1677.
60. Westerlund A, Bellocco R, Sundstrom J, Adami HO, Akerstedt T, Trolle Lagerros
Y. Sleep characteristics and cardiovascular events in a large Swedish cohort.
Eur J Epidemiol. 2013;28:463–473.
61. Sands-Lincoln M, Loucks EB, Lu B, Carskadon MA, Sharkey K, Stefanick ML,
Ockene J, Shah N, Hairston KG, Robinson JG, Limacher M, Hale L, Eaton CB.
Sleep duration, insomnia, and coronary heart disease among postmenopausal
women in the Women’s Health Initiative. J Womens Health (Larchmt).
2013;22:477–486.
62. Holliday EG, Magee CA, Kritharides L, Banks E, Attia J. Short sleep duration is
associated with risk of future diabetes but not cardiovascular disease: a
prospective study and meta-analysis. PLoS One. 2013;8:e82305.
63. Hamazaki Y, Morikawa Y, Nakamura K, Sakurai M, Miura K, Ishizaki M, Kido T,
Naruse Y, Suwazono Y, Nakagawa H. The effects of sleep duration on the
incidence of cardiovascular events among middle-aged male workers in Japan.
Scand J Work Environ Health. 2011;37:411–417.
64. von Ruesten A, Weikert C, Fietze I, Boeing H. Association of sleep duration
with chronic diseases in the European Prospective Investigation into Cancer
and Nutrition (EPIC)-Potsdam study. PLoS One. 2012;7:e30972.
65. Chandola T, Ferrie JE, Perski A, Akbaraly T, Marmot MG. The effect of short
sleep duration on coronary heart disease risk is greatest among those with
sleep disturbance: a prospective study from the Whitehall II cohort. Sleep.
2010;33:739–744.
66. Shankar A, Koh WP, Yuan JM, Lee HP, Yu MC. Sleep duration and coronary
heart disease mortality among Chinese adults in Singapore: a population-
based cohort study. Am J Epidemiol. 2008;168:1367–1373.
67. Meisinger C, Heier M, Lowel H, Schneider A, Doring A. Sleep duration and
sleep complaints and risk of myocardial infarction in middle-aged men and
women from the general population: the MONICA/KORA Augsburg cohort
study. Sleep. 2007;30:1121–1127.
68. Ayas NT, White DP, Manson JE, Stampfer MJ, Speizer FE, Malhotra A, Hu FB. A
prospective study of sleep duration and coronary heart disease in women.
Arch Intern Med. 2003;163:205–209.
69. Yang L, Yang H, He M, Pan A, Li X, Min X, Zhang C, Xu C, Zhu X, Yuan J,
Wei S, Miao X, Hu FB, Wu T, Zhang X. Longer sleep duration and midday
napping are associated with a higher risk of CHD incidence in middle-aged
and older Chinese: the Dongfeng-Tongji Cohort Study. Sleep. 2016;39:645–
652.
70. Ruiter Petrov ME, Letter AJ, Howard VJ, Kleindorfer D. Self-reported sleep
duration in relation to incident stroke symptoms: nuances by body mass and
race from the REGARDS study. J Stroke Cerebrovasc Dis. 2014;23:e123–e132.
71. Pan A, De Silva DA, Yuan JM, Koh WP. Sleep duration and risk of stroke
mortality among Chinese adults: Singapore Chinese Health Study. Stroke.
2014;45:1620–1625.
72. Kawachi T, Wada K, Nakamura K, Tsuji M, Tamura T, Konishi K, Nagata C. Sleep
duration and the risk of mortality from stroke in Japan: the Takayama Cohort
Study. J Epidemiol. 2016;26:123–130.
73. Chen JC, Brunner RL, Ren H, Wassertheil-Smoller S, Larson JC, Levine DW,
Allison M, Naughton MJ, Stefanick ML. Sleep duration and risk of ischemic
stroke in postmenopausal women. Stroke. 2008;39:3185–3192.
74. Ferrie JE, Shipley MJ, Cappuccio FP, Brunner E, Miller MA, Kumari M, Marmot
MG. A prospective study of change in sleep duration: associations with
mortality in the Whitehall II cohort. Sleep. 2007;30:1659–1666.
75. Albrektsen G, Heuch I, Lochen ML, Thelle DS, Wilsgaard T, Njolstad I, Bonaa
KH. Lifelong gender gap in risk of incident myocardial infarction: the Tromso
Study. JAMA Intern Med. 2016;176:1673–1679.
76. Grandner MA, Buxton OM, Jackson N, Sands-Lincoln M, Pandey A, Jean-Louis
G. Extreme sleep durations and increased C-reactive protein: effects of sex
and ethnoracial group. Sleep. 2013;36:769–779e.
77. Knutson KL, Turek FW. The U-shaped association between sleep and health:
the 2 peaks do not mean the same thing. Sleep. 2006;29:878–879.
78. Leproult R, Van Cauter E. Effect of 1 week of sleep restriction on testosterone
levels in young healthy men. JAMA. 2011;305:2173–2174.
79. Blask DE. Melatonin, sleep disturbance and cancer risk. Sleep Med Rev.
2009;13:257–264.
80. Brugger P, Marktl W, Herold M. Impaired nocturnal secretion of melatonin in
coronary heart disease. Lancet. 1995;345:1408.
81. Kloner RA, Carson C III, Dobs A, Kopecky S, Mohler ER III. Testosterone and
cardiovascular disease. J Am Coll Cardiol. 2016;67:545–557.
82. King CR, Knutson KL, Rathouz PJ, Sidney S, Liu K, Lauderdale DS. Short sleep
duration and incident coronary artery calcification. JAMA. 2008;300:2859–
2866.
83. Taheri S, Lin L, Austin D, Young T, Mignot E. Short sleep duration is associated
with reduced leptin, elevated ghrelin, and increased body mass index. PLoS
Med. 2004;1:e62.
84. Spiegel K, Tasali E, Penev P, Van Cauter E. Brief communication: sleep
curtailment in healthy young men is associated with decreased leptin levels,
elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med.
2004;141:846–850.
85. Sader S, Nian M, Liu P. Leptin: a novel link between obesity, diabetes,
cardiovascular risk, and ventricular hypertrophy. Circulation. 2003;108:644–
646.
86. Rodriguez A. Novel molecular aspects of ghrelin and leptin in the control of
adipobiology and the cardiovascular system. Obes Facts. 2014;7:82–95.
87. Morris CJ, Purvis TE, Hu K, Scheer FA. Circadian misalignment increases
cardiovascular disease risk factors in humans. Proc Natl Acad Sci USA.
2016;113:E1402–E1411.
88. Basner RC. Cardiovascular morbidity and obstructive sleep apnea. N Engl J
Med. 2014;370:2339–2341.
89. Youngstedt SD, Kripke DF. Long sleep and mortality: rationale for sleep
restriction. Sleep Med Rev. 2004;8:159–174.
90. Lim AS, Yu L, Schneider JA, Bennett DA, Buchman AS. Sleep fragmentation,
cerebral arteriolosclerosis, and brain infarct pathology in community-dwelling
older people. Stroke. 2016;47:516–518.
91. Grandner MA, Kripke DF. Self-reported sleep complaints with long and short
sleep: a nationally representative sample. Psychosom Med. 2004;66:239–
241.
92. Patel SR, Sotres-Alvarez D, Castaneda SF, Dudley KA, Gallo LC, Hernandez R,
Medeiros EA, Penedo FJ, Mossavar-Rahmani Y, Ramos AR, Redline S, Reid KJ,
Zee PC. Social and health correlates of sleep duration in a US Hispanic
population: results from the Hispanic Community Health Study/Study of
Latinos. Sleep. 2015;38:1515–1522.
DOI: 10.1161/JAHA.117.005947 Journal of the American Heart Association 14
Sleep Duration and Cardiovascular Events Yin et al
SYSTEMATIC REVIEW AND META-ANALYSIS
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93. Zuurbier LA, Luik AI, Hofman A, Franco OH, Van Someren EJ, Tiemeier H.
Fragmentation and stability of circadian activity rhythms predict mortality: the
Rotterdam study. Am J Epidemiol. 2015;181:54–63.
94. Ferguson T, Rowlands AV, Olds T, Maher C. The validity of consumer-level,
activity monitors in healthy adults worn in free-living conditions: a cross-
sectional study. Int J Behav Nutr Phys Act. 2015;12:42.
95. Hublin C, Partinen M, Koskenvuo M, Kaprio J. Sleep and mortality:
a population-based 22-year follow-up study. Sleep. 2007;30:
1245–1253.
96. Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V.
Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med.
2005;353:2034–2041.
DOI: 10.1161/JAHA.117.005947 Journal of the American Heart Association 15
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SUPPLEMENTAL MATERIAL
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Data S1.
Literature Search strategy：
PubMed：
((sleep duration) OR sleep length) AND (((cardiovascular disease) OR myocardial
infarction) OR coronary OR stroke OR death OR mortality OR mortalities OR fatal)
AND (cohort OR prospective OR (follow-up))
Embase：
'sleep'/exp OR sleep AND duration OR (sleep AND length) AND (cardiovascular AND
disease OR (myocardial AND infarction) OR coronary OR stroke OR death OR
mortality OR mortalities OR fatal) AND (cohort OR prospective OR 'follow-up')
Literature Search result:
After exclusion of duplicates and studies that did not fulfill the inclusion criteria, 101
remaining articles seemed to be relevant for this meta-analysis. After evaluating the
full texts of these 101 publications, we excluded 35 articles as follows:
Ten articles 68-77 were excluded owing to lack of sufficient data for estimation of RRs.
Three articles 78-80 were excluded because they reported all-cause mortality or
cardiovascular events combining with other diseases, and another four articles were
excluded because they did not separately report sleep duration 81-84. Fourteen studies
were excluded for providing less than three categories of sleep duration 85-98. We also
excluded two reports because only their abstracts were written in English 99, 100.Two
studies 101, 102 were excluded because they respectively reported the intermediate
follow-up results of the JACC Study and the Whitehall II cohort. After counting one
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study obtained by hand searching40, the final meta-analysis included 67 articles with
141 independent reports. Among these 67 articles, 43 articles with 57 reports provided
statistical effects relevant to the meta-analyses on all-cause mortality 1-43, 26 articles
with 37 reports on total CVD4, 7-9, 12-14, 17, 18, 23, 25-28, 31, 33, 34, 38, 44-51, 22 articles with 27
reports on CHD3, 11, 12, 16, 17, 28, 36, 44, 46, 47, 49-60, and 16 articles with 20 reports on
stroke4, 12, 17, 28, 47, 50, 51, 55, 60-67.
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Table S1. Sleep duration and all-cause mortality
Author,
publication year,
country
Study name
Age at
baseline
(years)
Follow-up
(years)
Exposure
Exposure
assessment
Sex, Sample
size(cases)
Sleep
categories
corresponding relative
risk (95% CI)
Covariates in fully adjusted model
Nisha Aurora et
al, 2016, US1
Sleep Heart
Health Study
≥40
10.8
Nighttime sleep
Interview
Both: 5784 (1509)
<7
7-8
≥9
0.98 (0.87 to 1.10)
1
1.25 (1.05 to 1.47)
Age, sex, race, BMI, smoking status, and prevalent
hypertension, cardiovascular disease, diabetes, AHI,
and antidepressant medications
Wei-Ju Lee et al,
2016, Taiwan2
The Social
Environment
and Biomarkers
of Aging Study
≥53
4.7
Nighttime sleep
Interview
Both: 937 (72)
<6
6-7
≥8
1.18 (0.66 to 2.12)
1
2.37 (1.35 to 4.19)
Age, sex, body mass index, education years,
smoking, drinking, and number of chronic diseases,
frailty states, use of hypnotics
Xizhu Wang et al,
2016, China3
Kailuan study
18-98
3.98
Nighttime sleep
Questionnaire
Both: 95903 (1793)
≤5
6
7
8
≥9
1.23 (1.03 to 1.8)
1.95 (0.81 to 1.12)
1
1.06 (0.92 to 1.2)
1.65 (1.22 to 2.22)
Age, sex, family per member monthly income,
education level, marital status, smoking status,
drinking status, physical activity, history of
hypertension, diabetes mellitus, and hyperlipidemia
Hui Cai et al,
2015, China4
Shanghai
Women’s and
Men’s Health
Studies
Male: 40-75
Female: 44-
79
Male: 6.07
Female: 7.12
24-hour sleep
Interview
Both: 113138 (4277)
Male: 44590 (1921)
Female: 68548
(2356)
Both:
4-5
6
7
8
9
≥10
Male:
4-5
6
7
8
9
≥10
Female:
4-5
6
7
8
9
≥10
Both:
1.11 (1.00 to 1.23)
1.06 (0.97 to 1.16)
1
1.15 (1.05 to 1.26)
1.34 (1.17 to 1.54)
1.81 (1.59 to 2.06)
Male:
1.06 (0.90 to 1.25)
1.07 (0.94 to 1.23)
1
1.13 (1.00 to 1.28)
1.34 (1.10 to 1.62)
1.55 (1.29 to 1.86)
Female:
1.15 (1.01 to 1.32)
1.06 (0.94 to 1.20)
1
1.17 (1.04 to 1.32)
1.36 (1.13 to 1.64)
2.11 (1.77 to 2.52)
Age, education, income, smoking, alcohol
consumption, tea consumption, comorbidity score,
history of night-shift work, participation in regular
exercise, body mass index, and waist-to-hip ratio,
cardiovascular disease, upper gastrointestinal tract
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Lisette A.
Zuurbier et al,
2015,
Netherlands5
Rotterdam
Study
45–98
7.3
Nighttime sleep
Questionnaire
Both: 1734 (154)
<6
6-7.5
>7.5
1.41(0.93 to 2.13)
1
1.10(0.74 to 1.64)
Age, sex, activities of daily living score, current
smoking, diabetes, myocardial infarction, stroke,
cognitive functioning, depressive symptoms, body
mass index, use of sleep medication, possible sleep
apnea, and napping
Martica H. Hall et
al, 2015, US6
Health, Aging
and Body
Composition
(Health ABC)
Study
70-79
8.2
Nighttime sleep
Interview
Both: 3013 (953)
<6
6
7
8
>8
1.06 (0.83 to 1.34)
1.00 (0.82 to 1.22)
1
1.10 (0.91 to 1.33)
1.23 (0.93 to 1.63)
Age, sex, race, education, BMI, smoking status,
alcohol consumption, physical activity, consumption
per week, site, chronic conditions, medication use
Naja Hulvej Rod
et al, 2014,
British7
British
Whitehall II
prospective
cohort study
35-55
22
Nighttime sleep
Questionnaire
Male: 6114 (538)
Female: 2984 (266)
Male:
≤5
6
7
8
>9
Female:
≤5
6
7
8
>9
Male:
1.11 (0.73 to 1.68)
1.23 (1.01 to 1.50)
1
1.18 (0.92 to 1.50)
1.44 (0.59 to 3.50)
Female:
1.21 (0.76 to 1.91)
1.14 (0.86 to 1.52)
1
0.91 (0.63 to 1.30)
1.48 (0.60 to 3.65)
Age, employment grade, ethnicity, and marital status
Qian Xiao et al,
2014, US8
National
Institutes of
Health-AARP
Diet and Health
Study
51-72
14
Nighttime sleep
Questionnaire
Both: 239896
(44100)
<5
5-6
7-8
≥9
1.16(1.10 to 1.23)
1.04(1.02 to 1.06)
1
1.11(1.06 to 1.19)
Sex , age, race/ethnicity , marital status, education,
self-reported health, smoking, smoking dose, years
since quitting smoking, alcohol drinking, moderate-
to-vigorous physical activity, TV viewing, and
baseline BMI
Andrea Bellavia
et al, 2014,
Sweden9
Cohort of
Swedish Men
and the Swedish
Mammography
Cohort
45-83
15
24-hour sleep
Questionnaire
Both: 70973 (14575)
<6
6–6.5
6.6–7.4
7.5–8
>8
1.25(1.13 to 1.37)
1.10(1.04 to 1.17)
1
1.03(0.98 to 1.08)
1.14(1.05 to 1.24)
Sex, age , body mass index , smoking status and
pack-years of smoking , alcohol consumption, total
physical activity, and educational level, total physical
activity
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Christopher A.
Magee et al,
2013, Australia10
45 and Up Study
≥45
2.8
24-hour sleep
Questionnaire
Both: 227815 (8782)
<6
6
7
8
9
≥10
1.13(1.01 to 1.25)
0.99(0.91 to 1.06)
1
1.02(0.96 to 1.08)
1.04(0.96 to 1.12)
1.26(1.16 to 1.36)
Age, sex, marital status, private health insurance,
smoking status, alcohol consumption, body mass
index, sufficient physical activity, and baseline health
status
Garde AH et al,
2013, Denmark11
Copenhagen
Male Study
40-59
30
24-hour sleep
Questionnaire
Both: 4943 (2663)
<6
6-7
≥8
1.06(0.90 to 1.25)
1
0.99(0.84 to 1.09)
Age, BMI, systolic BP, diastolic BP, diabetes ,
hypertension , physical fitness , alcohol use,
smoking, leisure-time physical activity, and social
class
Masako Kakizaki
et al, 2013,
Japan12
Ohsaki Cohort
Study
40-79
10.8
24-hour sleep
Questionnaire
Both: 49256 (8447)
≤6
7
8
9
≥10
1.01 (0.93 to 1.09)
1
1.07 (1.01 to 1.14)
1.14 (1.06 to 1.24)
1.37 (1.27 to 1.47)
Age, sex, total caloric intake, body mass index,
marital status, level of education, job status, history
of myocardial infarction, history of cancer, history of
stroke, history of hypertension, history of diabetes
mellitus, smoking status, alcohol drinking, time spent
walking, perceived mental stress, self-rated health,
physical function
Yohwan Yeo et
al, 2013, Korea13
Korean Multi-
center Cancer
Cohort study
>20
9.44
24-hour sleep
Interview
Both: 13164 (1580)
Male: 5447 (923)
Female: 7717 (657)
Both:
≤5
6
7
8
9
≥10
Male:
≤5
6
7
8
9
≥10
Female:
≤5
6
7
8
9
≥10
Both:
1.21 (1.03 to 1.41)
1.10 (0.95 to 1.27)
1
1.03 (0.89 to 1.19)
1.36 (1.11 to 1.67)
1.36 (1.07 to 1.72)
Male:
1.10 (0.89 to 1.36)
1.09 (0.90 to 1.30)
1
1.02 (0.85 to 1.23)
1.28 (0.97 to 1.69)
1.15 (0.85 to 1.56)
Female:
1.41 (1.12 to 1.79)
1.16 (0.92 to 1.46)
1
1.03 (0.81 to 1.30)
1.50 (1.11 to 2.02)
1.87 (1.28 to 2.73)
Age, sex, educational attainment, body mass index,
cigarette smoking, alcohol consumption, past history
of hypertension, type 2 diabetes, CVD and metabolic
syndrome
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Hsi-Chung Chen
et al, 2013,
Taiwan14
Shih-Pai Sleep
Study
>65
9
Nighttime sleep
Interview
Both: 4064 (1004)
≤4
5
6
7
8
9
1.00 (0.75 to 1.33)
0.92 (0.74 to 1.15)
0.88 (0.73 to 1.06)
1
1.26 (1.04 to 1.53)
1.66 (1.28 to 2.17)
Sex, age, education, marital status, living status,
depression, body mass index, insomnia, hypnotics
use, total sleep time, excessive daytime sleepiness,
pain, smoking, alcohol drinking, snorers, diabetes
mellitus, hypertension, cardiovascular disease,
stroke, and gouty arthritis
Kyu-In Jung et al,
2013, US15
Rancho
Bernardo Study
60-96
19
Nighttime sleep
Questionnaire
Male: 889 (632)
Female: 1112 (592)
Male:
<6
6.0-6.9
7.0-7.9
8.0-8.9
≥9
Female:
<6
6.0-6.9
7.0-7.9
8.0-8.9
≥9
Male:
0.98 (0.67 to 1.43)
1.12 (0.85 to 1.48)
1
0.98 (0.79 to 1.22)
1.09 (0.82 to 1.45)
Female:
1.11 (0.77 to 1.60)
1.17 (0.85 to 1.61)
1
1.19 (0.90 to 1.57)
1.51 (1.05 to 2.18)
Age, nap duration, Beck Depression Inventory (only
in men), education (only in men), exercise (only in
men), smoking (only in women), alcohol
consumption, and medical history of hypertension,
diabetes, coronary heart disease, stroke, and cancer,
sleep-related medications (sedating antidepressants,
antianxiety drugs, and hypnotics) and
postmenopausal estrogen (only in women)
Lauren Hale et al,
2013, US16
Women’s
Health Initiative
(WHI) clinical
trial (CT) and
observational
study (OS)
50-79
12–15
Nighttime sleep
Questionnaire
Female: 3942 (335)
≤5
6
7–8
≥9
1.01 (0.68 to 1.51)
0.94 (0.71 to 1.24)
1
1.55 (0.92 to 2.60)
Age, ethnicity, education, income, fibrinogen, body
mass index, low physical exercise, high alcohol
intake, ever smoke, elevated blood pressure, diabetes,
depression, general health, life satisfaction scale
Yeonju Kim et al,
2013, US17
Multiethnic
Cohort Study
45-75
12.9
24-hour sleep
Questionnaire
Male: 61936 (10738)
Female: 73749
(8597)
Male:
≤5
6
7
8
≥9
Female:
≤5
6
7
8
≥9
Male:
1.15 (1.06 to 1.23)
1.04 (0.99 to 1.10)
1
1.07 (1.01 to 1.12)
1.19 (1.12 to 1.27)
Female:
1.15 (1.06 to 1.23)
1.05 (0.99 to 1.12)
1
1.02 (0.96 to 1.08)
1.22 (1.13 to 1.31)
5-year age groups at cohort entry, sex, ethnicity,
education, marital status, history of hypertension or
diabetes at enrollment, alcohol consumption, energy
intake, body mass index, physical activity, hours
spent daily watching television, and smoking history
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Ying Li et al,
2013, Japan18
SAKU cohort
20-79
7
Nighttime sleep
Questionnaire
Both: 9455 (male:
181; female: 131)
Male:
≤5
6
7
8
9
Female:
≤5
6
7
8
9
Male:
1.44 (0.65 to 3.19)
0.86 (0.50 to 1.48)
1
1.05 (0.72 to 1.53)
1.70 (1.07 to 2.70)
Female:
1.01 (0.42 to 2.39)
1.01 (0.42 to 2.39)
1
1.01 (0.63 to 1.60)
1.85 (1.09 to 3.13)
Age, body mass index, systolic blood pressure,
diastolic blood press, smoking status, drinking habits
and physical activity
Jiska Cohen-
Mansfield et al,
2012, Israel19
Cross-Sectional
and
Longitudinal
Aging Study
75-94
20
Nighttime sleep
Interview
Both: 1166 (1108)
<7
7-9
>9
0.98(0.84 to 1.13)
1
1.32(1.09 to 1.58)
Age, sex, country of origin, education, financial
status, having children, demographics, health and
function variables
Chul Woo Rhee
et al, 2012,
Korea20
Seoul Male
Cohort Study
40-59
15
24-hour sleep
Questionnaire
Male: 14095 (935)
≤5
6-7
≥8
1.53 (1.11 to 2.12)
1.04 (0.88 to 1.22)
1
Age, smoking, alcohol drinking, BMI, regular
exercise, education level, hypertension, diabetes
mellitus
Castro-Costa et
al, 2011, Brasil21
Bambui Health
and Ageing
Study (BHAS)
≥60
7.5
Nighttime sleep
Interview
Both: 1512 (440)
<6
6-7
7-8
8-9
≥9
1.09 (0.78 to 1.53)
0.84 (0.60 to 1.17)
1
1.31 (0.97 to 1.78)
1.53 (1.12 to 2.09)
Age, schooling marital status, working status,
education, alcohol consumption, coffee consumption,
smoking, physical exercises, depressive symptoms,
cognitive functioning, psychoactive medications,
physical functioning, arthritis ascertainment, systolic
blood pressure, high-density lipoprotein cholesterol
ratio, diabetes mellitus and body mass index
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Li Qiu et al,
2011, China22
Chinese
Longitudinal
Healthy
Longevity
Survey
>65
3
24-hour sleep
Interview
Both: 20143 (8254)
Male: 8774 (3343)
Female: 11369
(4911)
Both:
≤5
6
7
8
9
≥10
Male:
≤5
6
7
8
9
≥10
Female:
≤5
6
7
8
9
≥10
Both:
0.97 (0.88 to 1.08)
1.05 (0.95 to 1.16)
1.00 (0.90 to 1.11)
1
0.95 (0.83 to 1.07)
1.09 (1.00 to 1.18)
Male:
1.17 (1.01 to 1.38)
1.06 (0.91 to 1.25)
1.17 (0.99 to 1.37)
1
1.08 (0.89 to 1.31)
1.22 (1.08 to 1.38)
Female:
0.85 (0.75 to 0.98)
1.02 (0.90 to 1.15)
0.88 (0.76 to 1.01)
1
0.86 (0.72 to 1.02)
1.00 (0.90 to 1.11)
Age, ethnicity, urban–rural residence, and geographic
region, SES, family/social support, and health
practices, health condition
Erkki Kronholm
et al, 2011,
Finland23
25-59,30-64
29–34
Nighttime sleep
Questionnaire
Male: 11373 (5241)
Female: 11917
(3747)
Male:
<5
6
7-8
9
>10
Female:
<5
6
7-8
9
>10
Male:
1.32(1.15 to 1.50)
1.09(0.99 to 1.20)
1
1.1 (0.99 to 1.21)
1.61(1.36 to 1.89)
Female:
1.25 (1.08 to 1.44)
1.14 (1.03 to 1.26)
1
1.18(1.05 to 1.32)
1.62(1.37 to 1.91)
Age, smoking, BMI, systolic blood pressure and total
cholesterol
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Arthur Eumann
Mesas et al, 2010,
Spain24
≥60
6.8
24-hour sleep
Interview
Both: 3820 (897)
Both:
≤5
6
7
8
9
10
≥11
Both:
1.42 (1.04 to 1.96)
1.23 (0.90 to 1.69)
1
1.34 (1.02 to 1.76)
1.48 (1.12 to 1.96)
1.73 (1.30 to 2.29)
1.66 (1.23 to 2.24)
Age, BMI, educational level, municipality of
residence, physical activity, smoking, alcohol
consumption, coffee consumption, social links,
perceived health, MEC score, depression, SF-36 PCS
and MCS scores, IADL limitations, hypertension,
ischemic heart disease, stroke, diabetes mellitus,
cancer at any site, chronic obstructive pulmonary
disease, Parkinson’s disease, arousal from sleep at
night, and use of anxiolytic medication
Kuo-Liong Chien
et al, 2010,
Taiwan25
Chin-shan
Community
Cardiovascular
Cohort Study
35
15.9
Nighttime sleep
Interview
Both: 3430 (901)
≤5
6
7
8
≥9
1.15 (0.90 to 1.46)
0.97 (0.79 to 1.21)
1
1.04 (0.86 to 1.27)
1.34 (1.08 to 1.67)
Age, sex, BMI, smoking, current alcohol
drinking, marital status, education level,
occupation, regular exercise, family history of
coronary heart disease, hypertension, diabetes,
cholesterol, HDL, triglyceride, glucose, and uric
acid level
Katie L. Stone et
al, 2009, US26
Study of
Osteoporotic
Fractures
prospective
cohort study
≥69
7
Nighttime sleep
and 24-hour
sleep
Questionnaire
Female: 8101 (1922)
nighttime
sleep:
<6
6-8
>8
24h sleep:
<6
6-8
8-9
9-10
≥10
nighttime sleep:
1.02 (0.87 to 1.19)
1
1.16 (0.97 to 1.39)
24h sleep:
0.95 (0.76 to 1.18)
1.07 (0.94 to 1.22)
1
1.28 (1.08 to 1.52)
1.58 (1.27 to 1.95)
Age, body mass index, history of at least one medical
condition including diabetes mellitus, Parkinson’s
disease, dementia, chronic obstructive pulmonary
disease, non-skin cancer, and osteoarthritis, history
of cardiovascular disease, history of hypertension,
walks for exercise, alcohol use, smoking status,
depression, cognitive impairment, estrogen use, and
benzodiazepine use
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Etsuji Suzuki et
al, 2009, Japan27
Shizuoka Study
65-85
5.3
Nighttime sleep
Questionnaire
Both: 11395 (1004)
Male: 5825 (689)
Female: 5570 (315)
Both:
≤5
6
7
8
9
≥10
Male:
≤5
6
7
8
9
≥10
Female:
≤5
6
7
8
9
≥10
Both:
0.92 (0.66 to 1.28)
1.06 (0.80 to 1.39)
1
1.36 (1.09 to 1.70)
1.41 (1.05 to 1.90)
1.96 (1.49 to 2.57)
Male:
1.08 (0.72 to 1.61)
1.05 (0.75 to 1.47)
1
1.36 (1.04 to 1.78)
1.52 (1.08 to 2.15)
1.86 (1.34 to 2.56)
Female:
0.71 (0.39 to 1.29)
1.08 (0.67 to 1.74)
1
1.39 (0.92 to 2.09)
1.15 (0.64 to 2.09)
2.27 (1.37 to 3.76)
Age, sex (only in the models for all participants),
body mass index, smoking status, alcohol
consumption, the frequency of physical activity,
socioeconomic status, and mental health,
hypertension and diabetes mellitus
Satoyo Ikehara et
al, 2009, Japan28
JACC Study
40-79
14.3
24-hour sleep
Questionnaire
Male: 41489 (8548)
Female: 57145
(5992)
Male:
<4
5
6
7
8
9
≥10
Female:
<4
5
6
7
8
9
≥10
Male:
1.29 (1.02 to 1.64)
1.02 (0.90 to 1.16)
1.08 (1.00 to 1.16)
1
1.06 (1.00 to 1.12)
1.13 (1.05 to 1.22)
1.41 (1.29 to 1.54)
Female:
1.28 (1.03 to 1.60)
1.11 (0.98 to 1.25)
1.05 (0.97 to 1.14)
1
1.16 (1.08 to 1.24)
1.32 (1.20 to 1.45)
1.56 (1.40 to 1.75)
Age, body mass index (quintiles), history of
hypertension, history of diabetes, alcohol
consumption, smoking, education level, hours of
exercise, hours of walking, regular employment,
perceived mental stress, depressive symptoms and
frequency of fresh fish intake
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James E.
Gangwisch et al,
2008, US29
NHANES I
Epidemiologic
Follow-up
Study
32-86
8–10
Nighttime sleep
Interview
Both: 9789 (1877)
≤5
6
7
8
≥9
1.17 (0.99 to 1.39)
0.95 (0.81 to 1.11)
1
1.23 (1.08 to 1.39)
1.34 (1.15 to 1.56)
Age, physical activity, smoking, depression, sex,
education, living alone, low income, daytime
sleepiness, nighttime awakening, ethnicity, and
sleeping pill use, body weight, diabetes, and
hypertension, general health and cancer
Christer Hublin et
al, 2007,
Finland30
Finnish Twin
Cohort
≥18
22
24-hour sleep
Questionnaire
Male: 10140 (2023)
Female: 11128
(1672)
Men:
<7
7-8
>8
Women:
<7
7-8
>8
Men:
1.26 (1.11 to 1.43)
1
1.24 (1.09 to 1.41)
Women:
1.21 (1.05 to 1.40)
1
1.17 (1.03 to 1.34)
Age, education, marital status, working status, social
class, BMI, smoking status, binge drinking, grams of
alcohol consumed daily, conditioning physical
activity, and life satisfaction
Tzuo-Yun Lan et
al, 2007,
Taiwan31
Survey of
Health and
Living Status of
the Elderly in
Taiwan
≥64
8.4
Nighttime sleep
Interview
Male: 1748 (816)
Female: 1331 (522)
Male:
<7
7-7.9
8-8.9
9-9.9
≥10
Female:
<7
7-7.9
8-8.9
9-9.9
≥10
Male:
0.98 (0.76 to 1.25)
1
1.09 (0.89 to 1.33)
1.14 (0.91 to 1.42)
1.51 (1.19 to 1.92)
Female:
1.14 (0.77 to 1.67)
1
1.36 (1.01 to 1.84)
1.86 (1.36 to 2.53)
2.06 (1.50 to 2.83)
Age at 1993, marital status, monthly income,
cigarettes smoking, alcohol consumption, body mass
index, exercise, disease history, depression,
afternoon nap duration
Yoko Amagai et
al, 2004, Japan32
Jichi Medical
School Cohort
Study
19-93
8.2
Nighttime sleep
Interview
Male: 4419 (289)
Female: 6906 (206)
Male:
<5.9
6.0-6.9
7.0-7.9
8.0-8.9
9.0-
Female:
-5.9
6.0-6.9
7.0-7.9
8.0-8.9
>9.0
Male:
2.4 (1.3 to 4.2)
1.1 (0.7 to 1.8)
1
0.9 (0.6 to 1.2)
1.1 (0.8 to 1.6)
Female:
0.7 (0.2 to 2.3)
1.3 (0.8 to 2.1)
1
1.1 (0.8 to 1.6)
1.5 (1.0 to 2.4)
Age, systolic blood pressure, total cholesterol, body
mass index, smoking habits, alcohol drinking habits,
education, and marital status
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Sanjay R. Patel et
al, 2003, US33
Nurses’ Health
Study (NHS)
Cohort
30-55
14
24-hour sleep
Questionnaire
Female: 82969
(5409)
Female:
≤5
6
7
8
≥9
Female:
1.08 (0.96 to 1.22)
0.99 (0.92 to 1.06)
1
1.11 (1.03 to 1.19)
1.40 (1.25 to 1.55)
Age, smoking status, alcohol consumption, physical
activity, depression, history of snoring, body mass
index, history of cancer, cardiovascular disease,
hypertension, or diabetes, and shift-working history
Genc Burazeri et
al, 2003, Israel34
Kiryat Yovel
Community
Health Study
≥50
10
Nighttime sleep
and 24-hour
sleep
Questionnaire
Male: 841 (198)
Female:1001 (205)
nighttime
sleep:
Male:
<6
6-8
>8
Female:
<6
6-8
>8
24h sleep :
Male :
<6
6-8
>8
Female:
<6
6-8
>8
nighttime sleep:
Male:
1
1.25(0.83 to 1.87)
1.91(1.16 to 3.13)
Female:
1
0.80(0.54 to 1.17)
1.08(0.70 to 1.66)
24h sleep :
Male :
1
1.41 (0.83 to 2.39)
2.13 (1.23 to 3.71)
Female:
1
0.64 (0.42 to 0.97)
0.80 (0.51 to 1.24)
Men: age, self-appraised health, activities of daily
living, CHD, alcohol consumption, systolic blood
pressure, homocysteine and glucose, siesta and its
duration
women: age, diabetes, congestive heart failure, BMI,
systolic blood pressure, and albumin, siesta and its
duration
Aya Goto et al,
2003, Japan35
≥65
12
Nighttime sleep
Questionnaire
Male: 251 (139)
Female: 473 (166)
Male:
<6
6-7
>7
Female:
<6
6-7
>7
Male:
1.29(0.50 to 3.34)
1
1.54(0.92 to 2.58)
Female:
2.62(1.36 to 5.07)
1
1.40(0.91 to 2.15)
Women: exercise, smoking, drinking, and social role,
age, presence of spouse, education, and working
status, activities of daily living, hearing, vision, and
basic activities of daily living, body mass index,
hemoglobin, serum albumin, total cholesterol,
creatinine, blood pressure, and electrocardiograph
abnormality
Men: exercise, smoking, drinking, and social role,
age, presence of spouse, education, and working
status, cerebrovascular disease, hypertension,
activities of daily living, hearing, vision, and basic
activities of daily living, body mass index,
hemoglobin, serum albumin, total cholesterol,
creatinine, blood pressure, and electrocardiograph
abnormality
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L. MALLON et
al, 2002,
Sweden36
45-65
12
Nighttime sleep
Questionnaire
Male: 906 (165)
Female: 964 (101)
Male:
<6
6-8
>8
Female:
<6
6-8
>8
Male:
1.1 (0.6 to 7.0)
1
2.0 (1.2 to 3.2)
Female:
1.0 (0.6 to 1.8)
1
1.3 (0.6 to 2.6)
Age
Daniel F. Kripke
et al, 2002, US37
Cancer
Prevention
Study II
30-102
6
Nighttime sleep
Questionnaire
Male: 480841
(45199)
Female: 636095
(32440)
Male:
3
4
5
6
7
8
9
≥10
Female:
3
4
5
6
7
8
9
≥10
Male:
1.19(0.96 to 1.47)
1.17(1.06 to 1.28)
1.11(1.05 to 1.18)
1.08(1.04 to 1.11)
1
1.12(1.09 to 1.15)
1.17(1.13 to 1.21)
1.34(1.28 to 1.40)
Female:
1.33(1.08 to 1.64)
1.11(1.01 to 1.22)
1.07(1.01 to 1.13)
1.07(1.03 to 1.11)
1
1.13(1.09 to 1.16)
1.23(1.17 to 1.28)
1.41(1.34 to 1.50)
Age, race education, occupation, marital status,
exercise level, smoking at intake, years of smoking,
churchgoing, fat in diet, fiber in diet, insomnia
frequency, health, body mass index, leg pain, history
of heart disease, history of hypertension, history of
cancer, history of diabetes, history of stroke, history
of bronchitis, history of emphysema, history of
kidney disease, medications
Pauline Heslop et
al, 2002, British38
65
25
24-hour sleep
Questionnaire
Male: 5819 (2303)
Female: 978(262)
Male:
<7
7-8
>8
Female:
<7
7-8
>8
Male:
1.00(0.89 to 1.12)
1
0.81(0.67 to 0.97)
Female:
0.98(0.70 to 1.37)
1
1.20(0.71 to 2.04)
Age, marital status, social class, known risk factors
for disease and self-perceived stress
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AHI; apnea hypopnea index, BMI; body mass index, BP; blood pressure, CVD; cardiovascular disease, CHD; coronary heart disease, HDL; high density lipoprotein, MEC; mini ex-amen cognoscitivo, MCS; mental component summary, PCS; physical
component summary, SES; socioeconomic status, SF-36; 36-item short form surve
Masayo Kojima
et al, 2000,
Japan39
20-67
11.9
Nighttime sleep
Questionnaire
Male: 2438 (149)
Female: 2884(109)
Male:
-6.9
7.0-8.9
9.0-9.9
10.0-
Female:
-6.9
7.0-8.9
9.0-9.9
10.0-
Male:
1.93(1.12 to 3.35)
1
1.15(0.74 to 1.77)
1.77(0.88 to 3.54)
Female:
0.90(0.50 to 1.61)
1
1.07(0.58 to 1.95)
0.40(0.06 to 2.92)
Baseline age, present and past history of
hypertension, cerebrovascular, heart and renal
diseases and diabetes, and use of sleeping pills
(smoking and drinking habits only in males)
Catharine Gale et
al, 1998, British40
≥65
23
Nighttime sleep
Interview
Both: 1229 (1158)
≤7
8
9
10
11
≥12
1.0 (0.7 to 1.4)
0.8 (0.7 to 1.0)
1
1.2 (1.0 to 1.4)
1.3 (1.0 to 1.7)
1.7 (1.2 to 2.5)
Age, sex, geriatrician’s diagnoses of illness, social
class, systolic blood pressure, and body mass index
Ana Ruigomez et
al, 1995, Spain41
Health Interview
Survey of
Barcelona
65
4.6
24-hour sleep
Interview
Both: 1219 (224)
Male: 470 (115)
Female: 749(109)
Both:
<7
7-9
>9
Male:
<7
7-9
>9
Female:
<7
7-9
>9
Both:
0.83(0.56 to 1.23)
1
1.37(0.89 to 2.11)
Male:
1.06(0.61 to 1.83)
1
1.30(0.71 to 2.38)
Female:
0.66(0.37 to 1.16)
1
1.46(0.79 to 2.70)
Age, sex, education level and self perceived health
status
Yoshitaka
Tsubono et al,
1993, Japan42
National
Collaborative
Cohort Study
≥40
4
Nighttime sleep
Questionnaire
Both: 4318 (207)
≤6
7-8
≥9
1.26(0.81 to 1.97)
1
1.58(1.16 to 2.15)
Age, sex
Roger Rumble et
al, 1992,
England43
Nottingham
Longitudinal
Study of
Activity
≥65
5
24-hour sleep
Interview
Both: 1042 (352)
<4
4.0-9.9
≥10
1.12(0.47 to 2.69)
1
1.60(0.74 to 3.47)
Sex, sleep pills, health
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Table S2. Sleep duration and total cardiovascular disease
Author,
publication year,
country
Study name
Age at
baseline
(years)
Follow-up
(years)
Exposure
Exposure
assessment
CVD
incidence or
mortality
Sex, Sample
size(cases)
Sleep
categories
corresponding relative
risk (95% CI)
Covariates in fully adjusted model
Francesco
Gianfagna et al,
2016, Italy44
MONICA
Brianza and
PAMELA
35-74
17
Nighttime sleep
Questionnaire
Incidence
Male: 2277 (293)
≤6
7-8
≥9
1.14 (0.84 to 1.53)
1
1.55 (1.08 to 2.21)
Age, systolic BP, total cholesterol,
HDL cholesterol, diabetes, smoking
habits, and educational level, sleep
disturbances, LTPA and depression
Hui Cai et al,
2015, China4
Shanghai
Women’s and
Men’s Health
Studies
Male: 40-75
Female: 44-79
male: 6.07
Female: 7.12
24-hour sleep
Interviews
Mortality
Both: 113138 (1389)
Both:
4-5
6
7
8
9
≥10
Male:
4-5
6
7
8
9
≥10
Female:
4-5
6
7
8
9
≥10
Both:
1.05 (0.87–1.26)
1.10 (0.94–1.29)
1
1.22 (1.05 to 1.43)
1.47 (1.17 to 1.85)
2.04 (1.65 to 2.53)
Male:
1.09 (0.82 to 1.46)
1.06 (0.83 to 1.34)
1
1.25 (1.00 to 1.56)
1.68 (1.23 to 2.30)
1.58 (1.14 to 2.18)
Female:
1.02 (0.80 to 1.30)
1.12 (0.91 to 1.39)
1
1.20 (0.96 to 1.50)
1.28 (0.91 to 1.82)
2.64 (1.99 to 3.52)
Age, education, income, smoking,
alcohol consumption, tea
consumption, comorbidity score,
history of night-shift work,
participation in regular exercise,
body mass index, and waist-to-hip
ratio, cardiovascular disease, upper
gastrointestinal tract
Catarina Canivet
et al, 2014,
Sweden45
Malmö Diet
and Cancer
Study
45-64
12
Nighttime sleep
Questionnaire
Incidence
Male: 5875 (952)
Female: 7742 (650)
Male:
≤6
7-8
≥9
Female:
≤6
7-8
≥9
Male:
1.1 (0.96 to 1.3)
1
1.3 (1.01 to 1.7)
Female:
1.3 (1.1 to 1.5)
1
1.5 (1.1 to 2.1)
Age
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Qian Xiao et al,
2014, US8
National
Institutes of
Health-
AARP Diet
and Health
Study
51-72
14
Nighttime sleep
Questionnaire
Mortality
Both: 239896
(11635)
<5
5-6
7-8
≥9
1.25(1.13 to 1.38)
1.06(1.02 to 1.10)
1
1.07(0.97 to 1.17)
Sex , age, race/ethnicity, marital
status, education, self-reported
health, smoking, smoking dose, years
since quitting smoking, alcohol
drinking, moderate-to-vigorous
physical activity, TV viewing, and
baseline BMI
Naja Hulvej Rod
et al, 2014,
British7
British
Whitehall II
prospective
cohort study
35-55
22
Nighttime sleep
Questionnaire
Mortality
Male: 6114 (167)
Female: 2984 (54)
Male:
≤6
7-8
>9
Female:
≤6
7-8
>9
Male:
1.18 (0.87 to 1.63)
1
1.61 (0.40 to 6.59)
Female:
1.81 (1.05 to 3.10)
1
NA(n=0)
Age, employment grade, ethnicity,
and marital status
Andrea Bellavia
et al, 2014,
Sweden9
Cohort of
Swedish Men
and the
Swedish
Mammograp
hy Cohort
45-83
15
24-hour sleep
Questionnaire
Mortality
Both: 70973 (3981)
<6
6–6.5
6.6–7.4
7.5–8
>8
1.44(1.20 to 1.73)
1.23(1.09 to 1.38)
1
1.02(0.92 to 1.12)
1.11(0.95 to 1.31)
Sex, age, body mass index ,smoking
status and pack-years of smoking,
alcohol consumption, total physical
activity, and educational level, total
physical activity
Megan Sands-
Lincoln et al,
2013, US46
Women’s
Health
Initiative
Observationa
l Study
50-79
10.3
Nighttime sleep
Questionnaire
Incidence
Female: 86329
(7257)
≤5
6
7-8
9
≥10
1.06(0.96 to 1.16)
1.00(0.95 to 1.06)
1
0.95(0.83 to 1.08)
1.23(0.89 to 1.70)
Age, race, education, income,
smoking, BMI, physical activity,
alcohol intake, depression, diabetes,
high blood pressure, hyperlipidemia,
comorbid conditions
Anna Westerlund
et al, 2013,
Sweden47
National
March
Cohort Study
≥18
13.2
24-hour sleep
Questionnaire
Incidence
and mortality
CVD incidence,
Both: 41192 (4031)
CVD mortality,
Both: 41192 (857)
≤5
6
7
≥8
5
6
7
≥8
1.05 (0.88 to 1.26)
0.97 (0.86 to 1.09)
1
1.00 (0.89 to 1.13)
1.11 (0.76 to 1.64)
1.17 (0.88 to 1.55)
1
1.12 (0.85 to 1.47)
Age, sex, education, employment
status, smoking, alcohol, snoring,
work schedule, depressive
symptoms, self-rated health, physical
activity, BMI, diabetes, lipid
disturbance, and hypertension
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Elizabeth G.
Holliday et al,
2013, Australia48
45 and Up
Study
≥45
2.3
Nighttime sleep
Questionnaire
Incidence
Both: 156902 (4852)
<6
6
7
8
9
≥10
1.03 (0.88 to 1.21)
1.06 (0.96 to 1.17)
1
0.98 (0.91 to 1.05)
0.98 (0.89 to 1.09)
1.00 (0.88 to 1.14)
Age, sex, education, marital status,
residential remoteness, alcohol
consumption, smoking status, health
insurance status, income, body mass
index, physical activity and baseline
health status
Yeonju Kim et al,
2013, US17
Multiethnic
Cohort Study
45-75
12.9
24-hour sleep
Questionnaire
Mortality
Male: 61936 (3772)
Female: 73749
(2838)
Male:
≤5
6
7
8
≥9
Female:
≤5
6
7
8
≥9
Male:
1.13 (1.00 to 1.28)
1.01 (0.92 to 1.11)
1
1.05 (0.96 to 1.14)
1.22 (1.09 to 1.35)
Female:
1.20 (1.05 to 1.36)
1.06 (0.96 to 1.18)
1
1.08 (0.98 to 1.20)
1.29 (1.13 to 1.47)
5-year age groups at cohort entry,
sex, ethnicity, education, marital
status, history of hypertension or
diabetes at enrollment, alcohol
consumption, energy intake, body
mass index, physical activity, hours
spent daily watching television, and
smoking history
Hsi-Chung Chen
et al, 2013,
Taiwan14
Shih-Pai
Sleep Study
>65
7
Nighttime sleep
Interviews
Mortality
Both: 4064 (259)
≤4
5
6
7
8
9
1.05 (0.61 to 1.79)
0.95 (0.62 to 1.48)
0.79 (0.54 to 1.16)
1
1.36 (0.92 to 2.01)
2.36 (1.46 to 3.80)
Sex, age, education, marital status,
living status, depression, body mass
index, insomnia, hypnotics use, total
sleep time, excessive daytime
sleepiness, pain, smoking, alcohol
drinking, snorers, diabetes mellitus,
hypertension, cardiovascular disease,
stroke, and gouty arthritis
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Yohwan Yeo et
al , 2013, Korea13
Korean
Multi-center
Cancer
Cohort study
>20
9.44
24-hour sleep
Interviews
Mortality
Both: 13164 (363)
Male: 5447 (169)
Female: 7717 (194)
Both:
≤5
6
7
8
9
≥10
Male:
≤5
6
7
8
9
≥10
Female:
≤5
6
7
8
9
≥10
Both:
1.40 (1.02 to 1.93)
1.25 (0.92 to 1.69)
1
1.04 (0.76 to 1.42)
1.26 (0.81 to 1.96)
1.37 (0.82 to 2.29)
Male:
1.43 (0.89 to 2.30)
1.21 (0.77 to 1.91)
1
1.06 (0.68 to 1.67)
1.05 (0.51 to 2.19)
1.53 (0.79 to 2.95)
Female:
1.48 (0.97 to 2.28)
1.32 (0.87 to 2.00)
1
1.00 (0.64 to 1.55)
1.40 (0.80 to 2.46)
1.13 (0.48 to 2.67)
Age, sex, educational attainment,
body mass index, cigarette smoking,
alcohol consumption, past history of
hypertension, type 2 diabetes, CVD
and metabolic syndrome
Masako Kakizki
et al, 2013,
Japan12
Ohsaki
Cohort Study
40-79
10.8
24-hour sleep
Questionnaire
Mortality
Both: 49256 (2549)
≤6
7
8
9
≥10
1.10 (0.96 to 1.28)
1
1.21 (1.08 to 1.36)
1.32 (1.15 to 1.52)
1.49 (1.30 to 1.71)
Age, sex, total caloric intake, body
mass index in, marital status, level of
education, job status , history of
myocardial infarction, history of
cancer, history of stroke, history of
hypertension, history of diabetes
mellitus, smoking status, alcohol
drinking, time spent walking,
perceived mental stress, self-rated
health, physical function
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Ying Li et al,
2013, Japan18
SAKU cohort
20-79
7
Nighttime sleep
Questionnaire
Mortality
Both: 9455 (NA)
Male:
≤5
6
7
8
≥9
Female:
≤5
6
7
8
≥9
Male:
1.57 (0.35 to 7.15)
0.60 (0.17 to 2.15)
1
1.04 (0.49 to 2.21)
2.73 (1.22 to 6.11)
Female:
0.80 (0.18 to 3.47)
0.91 (0.38 to 2.23)
1
1.13 (0.57 to 2.23)
1.72 (0.76 to 3.89)
Age, body mass index, systolic blood
pressure, diastolic blood press,
smoking status, drinking habits and
physical activity
Marieke P.
Hoevenaar-Blom
et al, 2011,
Netherlands49
MORGEN
Study
20-65
11.9
24-hour sleep
Questionnaire
Incidence
Both: 20432 (1486)
≤6
7
8
≥9
1.11 (0.97 to 1.27)
1
0.95 (0.84 to 1.08)
0.96 (0.77 to 1.18)
Age, sex, smoking, alcohol, coffee,
subjective health, educational level,
BMI, total-/HDL cholesterol ratio,
systolic blood pressure, CVD risk
factor medication, and prevalence of
type 2 diabetes
Yuko Hamazaki
et al, 2011,
Japan50
35-54
14
24-hour sleep
Questionnaire
Incidence
Male: 2282 (64)
<6
6-6.9
7-7.9
≥8
3.49(1.30 to 9.40)
1.11(0.55 to 2.25)
1
1.71(0.90 to 3.24)
Age, type of job, working hours,
mental workload, body mass index,
mean blood pressure, HbA1c, total
cholesterol, current smoking habit,
drinking habit, leisure–time physical
activity , medication for
hypertension, diabetes, and
hypercholesterolemia
Erkki Kronholm
et al, 2011,
Finland23
25-59,30-64
29-34
Nighttime sleep
Questionnaire
Mortality
Male: 10851 (1830)
Female: 11633
(1344)
Male:
< 5
6
7-8
9
> 10
Female:
< 5
6
7-8
9
> 10
Male:
1.20 (0.96 to 1.50)
1.12 (0.96 to 1.31)
1
0.95 (0.80 to 1.14)
1.27 (0.94 to 1.75)
Female:
1.33 (1.06 to 1.67)
1.20 (1.01 to 1.42)
1
1.20 (1.00 to 1.45)
1.76 (1.34 to 2.32)
Age, smoking, BMI, systolic blood
pressure and total cholesterol
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Kuo-Liong Chien
et al, 2010,
Taiwan25
Chin-shan
Community
Cardiovascul
ar Cohort
study
>35
15.9
Nighttime sleep
Interview
Incidence
Both: 3430 (420)
≤5
6
7
8
≥9
0.94 (0.65 to 1.35)
0.91 (0.67 to 1.24)
1
1.05 (0.80 to 1.39)
1.12 (0.81 to 1.55)
Age, sex, BMI, smoking, current
alcohol drinking, marital status,
education level, occupation, regular
exercise, family history of coronary
heart disease, baseline hypertension,
diabetes, cholesterol, HDL,
triglyceride, glucose, and uric acid
level
Yoko Amagai et
al, 2010, Japan51
Jichi Medical
School
Cohort Study
18-90
10.7
Nighttime sleep
Interview
Incidence
Male: 4413 (255)
Female: 6954 (226)
Male:
<5.9
6.0–6.9
7.0–7.9
8.0–8.9
9.0
Female:
<5.9
6.0–6.9
7.0–7.9
8.0–8.9
9.0
Male:
2.14 (1.11 to 4.13)
1.04 (0.61 to 1.76)
1
0.98 (0.69 to 1.40)
1.33 (0.93 to 1.92)
Female:
1.46 (0.70 to 3.04)
0.64 (0.38 to 1.10)
1
0.85 (0.60 to 1.20)
1.28 (0.88 to 1.87)
Age, systolic blood pressure, total
cholesterol, body mass index,
smoking habits, and alcohol drinking
habits
Katie L. Stone et
al, 2009, US26
Study of
Osteoporotic
Fractures
Prospective
Cohort study
≥69
7
Nighttime sleep
and 24-hour
sleep
Questionnaire
Mortality
Female: 8101 (723)
<6
6-8
>8
1.03 (0.80 to 1.31)
1
1.21 (0.92 to 1.61)
Age, body mass index, history of at
least one medical condition including
diabetes mellitus, Parkinson’s
disease, dementia, chronic
obstructive pulmonary disease, non-
skin cancer, and osteoarthritis,
history of cardiovascular disease,
history of hypertension, walks for
exercise, alcohol use, smoking status,
depression, cognitive impairment,
estrogen use, and benzodiazepine use
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Etsuji Suzuki et
al, 2009, Japan27
Shizuoka
Study
65-85
5.3
Nighttime sleep
Questionnaire
Mortality
Both: 11395 (310)
Male: 5825 (184)
Female: 5570 (126)
Both:
≤5
6
7
8
9
≥10
Male:
≤5
6
7
8
9
≥10
Female:
≤5
6
7
8
9
≥10
Both:
1.10 (0.62 to 1.93)
0.85 (0.50 to 1.45)
1
1.52 (1.01 to 2.29)
1.55 (0.91 to 2.63)
1.95 (1.18 to 3.21)
Male:
0.97 (0.46 to 2.05)
0.75 (0.38 to 1.48)
1
1.05 (0.63 to 1.75)
1.26 (0.65 to 2.45)
1.71 (0.94 to 3.11)
Female:
1.48 (0.59 to 3.67)
1.08 (0.44 to 2.66)
1
2.83 (1.39 to 5.76)
2.32 (0.93 to 5.77)
2.31 (0.91 to 5.82)
Age, sex (only in the models for all
participants), body mass index,
smoking status, alcohol consumption,
the frequency of physical activity,
socioeconomic status, and mental
health, hypertension and diabetes
mellitus
Satoyo Ikehara et
al, 2009, Japan28
JACC Study
40-79
14.3
24-hour sleep
Questionnaire
Mortality
Male :41489 (2297)
Female: 57145
(1990)
Male:
<4
5
6
7
8
9
≥10
Female:
<4
5
6
7
8
9
≥10
Male:
1.11 (0.67 to 1.83)
0.99 (0.77 to 1.27)
1.01 (0.87 to 1.18)
1
1.11 (1.00 to 1.24)
1.14 (0.99 to 1.32)
1.56 (1.33 to 1.83)
Female:
1.28 (0.88 to 1.86)
1.22 (1.00 to 1.50)
1.00 (0.86 to 1.16)
1
1.28 (1.14 to 1.44)
1.37 (1.17 to 1.62)
1.54 (1.28 to 1.86)
Age, body mass index (quintiles),
history of hypertension, history of
diabetes, alcohol consumption,
smoking, education level, hours of
exercise, hours of walking, regular
employment, perceived mental stress,
depressive symptoms and frequency
of fresh fish intake
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Tzuo-Yun Lan et
al, 2007, Taiwan31
Survey of
Health and
Living Status
of the Elderly
in Taiwan
≥64
8.4
Nighttime sleep
Interviews
Mortality
Male: 1748 (209)
Female: 1331 (170)
Male:
<7
7-7.9
8-8.9
9-9.9
≥10
Female:
<7
7-7.9
8-8.9
9-9.9
≥10
Male:
0.91 (0.53 to 1.57)
1
1.40 (0.93 to 2.10)
1.26 (0.80 to 1.98)
1.81 (1.13 to 2.89)
Female:
1.07 (0.54 to 2.15)
1
1.77 (1.05 to 2.98)
1.75 (1.00 to 3.07)
1.85 (1.04 to 3.27)
Age at 1993, marital status, monthly
income, cigarettes smoking, alcohol
consumption, body mass index,
exercise, disease history (heart
disease, stroke, and cancer),
depression, afternoon nap duration
Sanjay R. Patel et
al, 2004, US33
Nurses’
Health Study
(NHS)
Cohort
30-55
14
24-hour sleep
Questionnaire
Mortality
Female: 82969
(1084)
≤5
6
7
8
≥9
1.04 (0.79 to 1.35)
1.06 (0.91 to 1.25)
1
1.12 (0.95 to 1.31)
1.56 (1.25 to 1.96)
Age, smoking status, alcohol
consumption, physical activity,
depression, history of snoring, body
mass index, history of cancer,
cardiovascular disease, hypertension,
or diabetes, and shift-working history
Genc Burazeri et
al, 2003, Israel34
Kiryat Yovel
Community
Health Study
≥50
10
Nighttime sleep
and 24-hour
sleep
Questionnaire
Mortality
Male: 750 (77)
Female: 910 (93)
Male:
<6
6-8
>8
Female:
<6
6-8
>8
Male:
1
1.35 (0.71 to 2.58)
1.91 (0.86 to 4.23)
Female:
1
0.83 (0.47 to 1.45)
1.02 (0.54 to 1.93)
Men included: age, self-appraised
health, activities of daily living,
CHD, alcohol consumption, systolic
blood pressure, homocysteine,
glucose, siesta and its duration
Women included: age, diabetes,
congestive heart failure, BMI ,
systolic blood pressure, albumin,
siesta and its duration
Pauline Heslop et
al, 2002, British38
Male: 65
Female: 60
25
24-hour sleep
Questionnaire
Mortality
Male: 5819 (1182)
Female: 978 (117)
Male:
<7
7-8
>8
Female:
<7
7-8
>8
Male:
1.00 (0.85 to 1.17)
1
0.82 (0.64 to 1.07)
Female:
0.80 (0.47 to 1.37)
1
1.35 (0.62 to 2.95)
Age, marital status, social class,
known risk factors for disease and
self-perceived stress
BMI; body mass index, BP; blood pressure, CVD; cardiovascular disease, CHD; coronary heart disease, HDL; high density lipoprotein, LTPA; leisure time physical activity, NA; not available
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Table S3. Sleep duration and coronary heart disease
Author,
publication year,
country
Study name
Age at
baseline
(years)
Follow-up
(years)
Exposure
Exposure
assessment
Outcome
Sex, Sample
size(cases)
Sleep
categories
Corresponding relative risk
(95% CI)
Covariates in fully adjusted model
Francesco
Gianfagna et al,
2016, Italy44
MONICA
Brianza and
PAMELA
Population-
based
Cohorts
35-74
17
Nighttime
sleep
Questionnaire
CHD incidence
Male: 2277 (213)
≤6
7-8
≥9
1.14 (0.80 to 1.61)
1
1.32 (0.85 to 2.07)
Age, systolic BP, total cholesterol, HDL
cholesterol, diabetes, smoking habits,
and educational level, sleep
disturbances, LTPA and depression
Liangle Yang et
al, 2016, China52
Dongfeng-
Tongji
Cohort Study
62.8
3-5
Nighttime
sleep
Questionnaire
CHD incidence
Both: 19370 (2058)
<7
7-<8
8-<9
9-<10
≥10
1.08 (0.90 to 1.29)
1
1.04 (0.93 to 1.16)
1.03 (0.90 to 1.18)
1.33 (1.10 to 1.62)
Age, sex, BMI, education, smoking
status, drinking status, physical activity,
hypertension, hyperlipidemia, diabetes,
family history of CHD, and midday
napping
Xizhu Wang et al,
2016, China3
Kailuan
Study
18-98
3.98
Nighttime
sleep
Questionnaire
MI mortality
Both: 95903 (423)
≤5
6
7
8
≥9
0.89 (0.60 to 1.30)
0.84 (0.61 to 1.16)
1
0.86 (0.66 to 1.13)
1.12 (0.58 to 2.16)
Age, sex, family per member monthly
income, education level, marital status,
smoking status, drinking status, physical
activity, history of hypertension,
diabetes mellitus, and hyperlipidemia
Linn B. Strand et
al, 2016, Taiwan53
≥20
9.7
Nighttime
sleep
Questionnaire
CHD mortality
Both: 392164 (711)
Male: 191656 (489)
Female: 200508
(222)
Both:
0-4
4-6
6-8
>8
Male:
0-4
4-6
6-8
>8
Female:
0-4
4-6
6-8
>8
Both:
1.36 (0.88 to 2.10)
1.03 (0.85 to 1.24)
1
1.28 (1.05 to 1.56)
Male:
1.03 (0.53 to 2.00)
1.06 (0.85 to 1.32)
1
1.11 (0.88 to 1.41)
Female:
1.84 (1.03 to 3.29)
0.99 (0.72 to 1.37)
1
1.81 (1.28 to 2.56)
Age, sex, education, marital status,
smoking, alcohol consumption, physical
activity, history of hypertension, history
of diabetes, history of heart disease,
body mass index, systolic blood
pressure, fasting glucose, total
cholesterol, HDL cholesterol,
triglycerides and use of
hypnotics/sedatives
J. Liu et al, 2014,
US54
Framingham
Offspring
Study
≥30
20
24-hour sleep
Questionnaire
CHD incidence
Both: 3086 (491)
<6
7-8
>9
1.29 (1.03 to 1.61)
1
1.13 (0.81 to 1.58)
Age, sex, current cigarette smoking,
weekly alcohol drinking, systolic blood
pressure, total cholesterol level, BMI,
diabetes, treatment of hypertension, C-
reactive protein
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Megan Sands-
Lincoln et al,
2013, US46
Women’s
Health
Initiative
Observationa
l Study
50-79
10.3
Nighttime
sleep
Questionnaire
CHD incidence
Female: 86329
(5359)
≤5
6
7-8
9
≥10
1.08 (0.96 to 1.20)
1.00 (0.94 to 1.07)
1
0.93 (0.80 to 1.08)
1.33 (0.94 to 1.88)
Age, race, education, income, smoking,
BMI, physical activity, alcohol intake,
depression, diabetes, high blood
pressure, hyperlipidemia, comorbid
conditions
Lauren Hale et al,
2013, US16
Women’s
Health
Initiative
(WHI)
clinical trial
(CT) and
observational
study (OS)
50-79
11-16
Nighttime
sleep
Questionnaire
CHD incidence
Female:3942 (132)
≤5
6
7–8
≥9
1.09 (0.63 to 1.89)
0.66 (0.42 to 1.04)
1
1.88 (0.92 to 3.83)
Age, ethnicity, education, income,
fibrinogen, body mass index, low
physical exercise, high alcohol intake,
ever smoke, elevated blood pressure,
diabetes, depression, general health, life
satisfaction scale
Yeonju Kim et al,
2013, US17
Multiethnic
Cohort Study
45-75
12.9
24-hour sleep
Questionnaire
CHD mortality,
IHD mortality and
MI mortality
CHD mortality,
Male: 61936 (2096)
Female: 73749
(1380)
IHD mortality, Male:
61936 (1429)
Female: 73749 (859)
MI mortality, Male:
61936 (667)
Female: 73749 (521)
Male:
≤5
6
7
8
≥9
Female:
≤5
6
7
8
≥9
Male:
≤5
6
7
8
≥9
Female:
≤5
6
7
8
≥9
Male:
≤5
6
7
8
Male:
1.20 (0.99 to 1.45)
0.98 (0.84 to 1.13)
1
1.01 (0.88 to 1.16)
1.16 (0.98 to 1.39)
Female:
1.18 (0.94 to 1.49)
1.06 (0.88 to 1.29)
1
1.13 (0.94 to 1.36)
1.20 (0.95 to 1.53)
Male:
1.24 (0.94 to 1.64)
0.92 (0.74 to 1.15)
1
0.98 (0.80 to 1.20)
1.16 (0.89 to 1.50)
Female:
1.18 (0.87 to 1.59)
1.23 (0.96 to 1.56)
1
1.10 (0.86 to 1.40)
1.29 (0.94 to 1.75)
1.21 (1.04 to 1.42)
0.96 (0.85 to 1.08)
1
1.00 (0.89 to 1.12)
1.16 (1.00 to 1.34)
5-year age groups at cohort entry, sex,
ethnicity, education, marital status,
history of hypertension or diabetes at
enrollment, alcohol consumption, energy
intake, body mass index, physical
activity, hours spent daily watching
television, and smoking history
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≥9
Female:
≤5
6
7
8
≥9
Female:
1.18 (0.98 to 1.42)
1.13 (0.97 to 1.31)
1
1.12 (0.96 to 1.29)
1.23 (1.02 to 1.49)
Masako Kakizki
et al, 2013,
Japan12
Ohsaki
Cohort Study
40-79
10.8
24-hour sleep
Questionnaire
IHD mortality
Both:49256 (561)
≤6
7
8
9
≥10
1.38 (1.02 to 1.86)
1
1.36 (1.06 to 1.73)
1.49 (1.10 to 2.02)
1.41 (1.04 to 1.92)
Age, sex, total caloric intake, body mass
index, marital status, level of education,
job status, history of myocardial
infarction, history of cancer, history of
stroke, history of hypertension, history
of diabetes mellitus, smoking status ,
alcohol drinking , time spent walking,
perceived mental stress, self-rated
health, physical function
Garde AH et al,
2013, Denmark11
Copenhagen
Male Study
40-59
30
24-hour sleep
Questionnaire
IHD mortality
Male: 4943 (587)
Male:
<6
6-7
≥8
Male:
1.46 (1.07 to 2.00)
1
1.20 (0.97 to 1.49)
Age, BMI, systolic BP, diastolic BP,
diabetes, hypertension, physical fitness,
alcohol use, smoking, leisure-time
physical activity, and social class.
Anna Westerlund
et al, 2013,
Sweden47
National
March
Cohort Study
≥18
13.2
24-hour sleep
Questionnaire
MI incidence
Both: 41192 (1908)
5
6
7
≥8
1.19 (0.92 to 1.55)
1.05 (0.88 to 1.25)
1
1.19 (1.00 to 1.41)
Age, sex, education, employment status,
smoking, alcohol, snoring, work
schedule, depressive symptoms, self-
rated health, physical activity, BMI,
diabetes, lipid disturbance, and
hypertension
Anne von Ruesten
et al, 2012,
Germany55
European
Prospective
Investigation
into Cancer
and Nutrition
(EPIC)-
Potsdam
Study
Male: 65
Female:
60
7.8
24-hour sleep
Interview
MI incidence
Both: 23620 (197)
<6
6-7
7-8
8-9
≥9
1.44 (0.85 to 2.43)
0.80 (0.53 to 1.20)
1
0.82 (0.56 to 1.19)
0.89 (0.54 to 1.49)
Age, sex, sleeping disorders, sleep
duration at night, alcohol intake from
beverages, smoking status, walking,
cycling, sports, employment
status, and education, BMI, waist-to-hip
ratio, history of high blood lipid levels at
baseline.
Marieke P.
Hoevenaar-Blom
et al, 2011,
Netherlands49
MORGEN
Study
20-65
11.9
24-hour sleep
Questionnaire
CHD incidence
Both: 20432 (1148)
≤6
7
8
≥9
1.19 (1.00 to 1.40)
1
0.85 (0.73 to 1.00)
0.78 (0.58 to 1.04)
Age, sex, smoking, alcohol, coffee,
subjective health, educational level,
BMI, total-/HDL cholesterol ratio,
systolic blood pressure, CVD risk factor
medication, and prevalence of type 2
diabetes
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Yuko Hamazaki
et al, 2011,
Japan50
35-54
14
24-hour sleep
Questionnaire
CHD incidence
Male: 2282 (27)
<6
6-6.9
7-7.9
≥8
4.95 (1.31 to 18.73)
1.12 (0.40 to 3.13)
1
1.78 (0.67 to 4.76)
Age, type of job, working hours, and
mental workload, body mass index,
mean blood pressure, HbA1c, total
cholesterol, current smoking habit,
drinking habit, leisure–time physical
activity , and medication for
hypertension, diabetes, and
hypercholesterolemia
Tarani Chandola
et al, 2010,
British56
British
Whitehall II
Prospective
Cohort Study
35-55
15
Nighttime
sleep
Questionnaire
CHD incidence
Both: 8998 (1025)
≤5
6
7
≥8
1.05 (0.92 to 1.20)
0.98 (0.83 to 1.16)
1
0.99 (0.77 to 1.27)
Sleep variables, age, sex, ethnicity,
employment grade, car access, and
housing tenure, self-rated health status,
total cholesterol concentration,
hypertension, body mass index, diabetes,
smoking, alcohol consumption, vigorous
and moderate exercise, and fruit and
vegetable consumption
Yoko Amagai et
al, 2010, Japan51
Jichi Medical
School
Cohort Study
18-90
10.7
Nighttime
sleep
Interview
MI incidence
Male: 4413 (55)
Female: 6954 (25)
Male:
<5.9
6.0–6.9
7.0–7.9
8.0–8.9
9.0
Female:
<5.9
6.0–6.9
7.0–7.9
8.0–8.9
9.0
Male:
1.78 (0.50 to 6.28)
0.77 (0.25 to 2.33)
1
0.69 (0.34 to 1.41)
0.99 (0.47 to 2.06)
Female:
4.93 (1.31 to 18.61)
0.59 (0.13 to 2.73)
1
0.59 (0.21 to 1.66)
0.84 (0.27 to 2.62)
Age, systolic blood pressure, total
cholesterol, body mass index, smoking
habits, and alcohol drinking habits.
Satoyo Ikehara et
al, 2009, Japan28
JACC Study
40-79
14.3
24-hour sleep
Questionnaire
CHD mortality
Male: 41489 (508)
Female: 57145 (373)
Male:
<4
5
6
7
8
9
≥10
Female:
<4
5
6
7
8
Male:
0.29 (0.04 to 2.05)
1.02 (0.62 to 1.70)
0.86 (0.63 to 1.19)
1
1.02 (0.82 to 1.27)
0.96 (0.70 to 1.31)
1.12 (0.77 to 1.63)
Female:
2.32 (1.19 to 4.50)
1.64 (1.07 to 2.53)
1.23 (0.88 to 1.72)
1
1.24 (0.94 to 1.64)
Age, body mass index , history of
hypertension, history of diabetes,
alcohol consumption, smoking,
education level, hours of exercise, hours
of walking, regular employment,
perceived mental stress, depressive
symptoms and frequency of fresh fish
intake
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9
≥10
1.52 (1.05 to 2.19)
1.04 (0.63 to 1.72)
Anoop Shankar et
al, 2008,
Singapore57
Singapore
Chinese
Health Study
≥45
13
Nighttime
sleep
Interview
CHD mortality
Both: 58044 (1416)
Male: 25552 (846)
Female: 32492 (570)
Both:
≤5
6
7
8
≥9
Male:
≤5
6
7
8
≥9
Female:
≤5
6
7
8
≥9
Both:
1.57 (1.32 to 1.88)
1.13 (0.98 to 1.31)
1
1.12 (0.97 to 1.29)
1.79 (1.48 to 2.17)
Male:
1.70 (1.35 to 2.15)
1.20 (0.99 to 1.45)
1
1.10 (0.92 to 1.32)
1.88 (1.48 to 2.40)
Female:
1.43 (1.09 to 1.88)
1.04 (0.82 to 1.31)
1
1.15 (0.92 to 1.44)
1.67 (1.24 to 2.27)
Age, sex, dialect group, education, year
of recruitment, body mass index,
smoking , alcohol intake, moderate
physical activity , dietary intakes of total
calories , fruits, vegetables , fiber, total
fat and cholesterol , weekly use of
vitamin/mineral supplements (among
women, menopausal statusand ever use
of postmenopausal hormone
replacement therapy)
Christa Meisinger
et al, 2007,
Germany58
MONICA/K
ORA
Augsburg
Cohort Study
45-74
10.1
Nighttime
sleep
Interview
MI incidence
Male: 3508 (295)
Female: 3388 (85)
Male:
5
6
7
8
≥9
Female:
5
6
7
8
≥9
Male:
1.13 (0.66 to 1.92)
1.05 (0.71 to 1.55)
1.22 (0.92 to 1.61)
1
1.07 (0.75 to 1.53)
Female:
2.98 (1.48 to 6.03)
1.05 (0.49 to 2.27)
1.34 (0.75 to 2.40)
1
1.40 (0.74 to 2.64)
Age, survey, BMI, education,
dyslipidemia, alcohol intake, parental
history of MI, physical activity, regular
smoking, hypertension, diabetes, and
menopause status (only women)
Najib T.Ayas et
al, 2003, US59
Nurse's
Health Study
35-55
10
Nighttime
sleep
Questionnaire
CHD incidence ,
CHD mortality
and MI incidence
CHD incidence,
Female: 71617 (934)
CHD mortality,
Female: 71617 (271)
≤5
6
7
8
≥9
5
6
7
8
1.39 (1.05 to 1.84)
1.18 (0.98 to 1.43)
1.10 (0.92 to 1.31)
1
1.37 (1.02 to 1.85)
1.12 (0.68 to 1.84)
0.91 (0.65 to 1.28)
0.83 (0.60 to 1.14)
1
Age, shift work, hypercholesterolemia,
body mass index, smoking, snoring,
exercise level, alcohol consumption,
depression, aspirin use, postmenopausal
hormone use, family history of MI,
diabetes mellitus and hypertension
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MI incidence,
Female: 71617 (663)
≥9
≤5
6
7
8
≥9
1.45 (0.89 to 2.36)
1.52 (1.08 to 2.14)
1.32 (1.05 to 1.65)
1.23 (0.99 to 1.52)
1
1.35 (0.93 to 1.95)
L. MALLON et
al, 2002,
Sweden36
45-65
12
Nighttime
sleep
Questionnaire
CHD incidence
Male: 906 (71)
Female: 964 (20)
Male:
<6
6-8
>8
Female:
<6
6-8
>8
Female:
<6
6-8
>8
Male:
0.7 (0.3 to 1.7)
1
2.2 (1.0 to 4.4)
Female:
1.2 (0.4 to 4.2)
1
0.7 (0.1 to 5.2)
Female:
1.2 (0.4 to 4.2)
1
0.7 (0.1 to 5.2)
Age
Adnan I. Qureshi
et al, 1997, US60
First
National
Health and
Nutrition
Examination
Survey
Epidemiologi
c Follow-up
Study
32-74
10
Nighttime
sleep
Questionnaire
CHD incidence
Both: 7844 (413)
<6
6-8
>8
1.3 (1.0 to 1.8)
1
1.1 (0.8 to 1.5)
Age, sex, race, education, cigarette
smoking, systolic blood pressure, serum
cholesterol level, diabetes, and body
mass index
BMI; body mass index, BP; blood pressure, CVD; cardiovascular disease, CHD; coronary heart disease, HDL; high density lipoprotein, IHD; ischemic heart disease, LTPA; leisure time physical activity, MI; myocardial infarction
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Table S4. Sleep duration and stroke
Author,
publication year,
country
Study name
Age at
baseline
(years)
Follow-up
(years)
Exposure
Exposure
assessment
Stroke incidence
or mortality
Sex, Sample
size(cases)
Sleep
categories
corresponding relative risk
(95% CI)
Covariates in fully adjusted model
Qiaofeng Song et
al, 2016, China61
The Kailuan
Study
18-98
7.9
Nighttime
sleep
Questionnaire
Incidence
Both: 95023 (3135)
<6
6-8
>8
0.92 (0.80 to 1.05)
1
1.29 (1.01 to 1.65)
Age, sex, marital status, family per
member monthly income, education
level, smoking status, drinking status,
physical activity, family history of
stroke, body mass index, systolic blood
pressure, diastolic blood pressure,
fasting blood glucose, total cholesterol,
hypotensive drug use, lipid-lowering
drug use, hypoglycemic drug use,
history of myocardial infarction, and
snoring status, sensitive C-reactive
protein, and atrial fibrillation
Toshiaki Kawachi
et al, 2016,
Japan62
Takayama
Cohort Study
≥35
16
Nighttime
sleep
Questionnaire
Mortality
Both: 27896 (611)
Male: 12875 (296)
Female: 15021 (315)
Both:
≤6
7
8
≥9
Male:
≤6
7
8
≥9
Female:
≤6
7
8
≥9
Both:
0.77 (0.59 to 1.01)
1
1.13 (0.91 to 1.40)
1.51 (1.16 to 1.97)
Male:
0.51 (0.34 to 0.77)
1
0.88 (0.66 to 1.17)
1.23 (0.90 to 1.69)
Female:
1.06 (0.75 to 1.50)
1
1.50 (1.10 to 2.04)
1.93 (1.38 to 2.70)
Sex, age, education years, marital status,
histories of hypertension and diabetes,
body mass index, physical activity score,
smoking status, and alcohol
consumption
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A. Katharina
Helbig et al, 2015,
Germany63
MONICA/K
ORA
Augsburg
Cohort Study
25-74
14
24-hour sleep
Interview
Incidence and
mortality
Stroke incidence,
Male: 6157 (508)
Female: 5974 (318)
Stroke mortality,
Male: 6157 (109)
Female: 5974 (89)
Male:
≤5
6
7-8
9
≥10
Female:
≤5
6
7-8
9
≥10
Male:
≤5
6
7-8
9
≥10
Female:
≤5
6
7-8
9
≥10
Male:
1.36 (0.95 to 1.94)
0.92 (0.70 to 1.22)
1
1.05 (0.78 to 1.43)
1.38 (0.98 to 1.94)
Female:
0.68 (0.40 to 1.18)
1.25 (0.91 to 1.70)
1
1.09 (0.76 to 1.57)
0.91 (0.55 to 1.51)
Male:
1.36 (0.95 to 1.94)
0.92 (0.70 to 1.22)
1
1.05 (0.78 to 1.43)
1.38 (0.98 to 1.94)
Female:
0.68 (0.40 to 1.18)
1.25 (0.91 to 1.70)
1
1.09 (0.76 to 1.57)
0.91 (0.55 to 1.51)
Age, survey, education, physical
activity, alcohol consumption, current
smoking, dyslipidemia activity, BMI,
hypertension, diabetes
Yue Leng et al,
2015, British64
European
Prospective
Investigation
of Cancer–
Norfolk
Cohort Study
42-81
9.5
24-hour sleep
Questionnaire
Incidence
Both: 9692 (346)
Male: 4444 (198)
Female: 5248 (148)
Both:
<6
6-8
>8
Male:
<6
6-8
>8
Female:
<6
6-8
>8
Both:
1.18 (0.91 to 1.53)
1
1.46 (1.08 to 1.98)
Male:
1.08 (0.75 to 1.57)
1
1.21 (0.80 to 1.82)
Female:
1.25 (0.86 to 1.83)
1
1.80 (1.13 to 2.85)
Age, sex, social class, education, marital
status, smoking, alcohol intake, hypnotic
drug use, family history of stroke, body
mass index, physical activity,
depression, hypnotic drug use, systolic
blood pressure, diastolic blood pressure,
preexisting diabetes and myocardial
infarction, cholesterol level, and
hypertension drug use
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Hui Cai et al,
2015, China4
Shanghai
Women’s
and Men’s
Health
Studies
Male: 40-
75
Female:
44-79
male:
6.07
Female:
7.12
24-hour sleep
Interview
Mortality
Both: 113138 (746)
Both:
4-5
6
7
8
9
≥10
Male:
4-5
6
7
8
9
≥10
Female:
4-5
6
7
8
9
≥10
Both:
0.91 (0.70 to 1.18)
0.99 (0.79 to 1.23)
1
1.28 (1.04 to 1.58)
1.31 (0.94 to 1.82)
2.35 (1.78 to 3.09)
Male:
0.93 (0.62 to 1.40)
0.78 (0.55 to 1.10)
1
1.20 (0.89 to 1.62)
1.62 (1.06 to 2.48)
1.73 (1.14 to 2.64)
Female:
0.92 (0.65 to 1.29)
1.14 (0.85 to 1.52)
1
1.36 (1.01 to 1.82)
0.98 (0.58 to 1.66)
3.09 (2.14 to 4.47)
Age, education, income, smoking,
alcohol consumption, tea consumption,
comorbidity score, history of night-shift
work, participation in regular exercise,
body mass index, and waist-to-hip ratio,
cardiovascular disease, upper
gastrointestinal tract
Megan E. Ruiter
Petrov et al, 2014,
US65
Reasons for
Geographic
And Racial
Differences
in
Stroke
(REGARDS)
Study
≥45
3
Nighttime
sleep
Questionnaire
Incidence
Both: 5666 (224)
< 6
6-6.9
7-7.9
8-8.9
≥ 9
1.43 (0.88 to 2.32)
1.16 (0.79 to 1.69)
1
1.17 (0.84 to 1.62)
1.44 (0.86 to 2.42)
Age, race, sex, income, education,
region
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An Pan et al,
2014, Singapore66
Singapore
Chinese
Health Study
45-74
14.7
24-hour sleep
Questionnaire
Mortality
Both: 63257 (1381)
Male: 27954 (693)
Female: 35303 (688)
Both:
≤5
6
7
8
≥9
Male:
≤5
6
7
8
≥9
Female:
≤5
6
7
8
≥9
Both:
1.25 (1.05 to 1.50)
1.01 (0.87 to 1.18)
1
1.09 (0.95 to 1.26)
1.54 (1.28 to 1.85)
Male:
1.13 (0.86 to 1.47)
0.93 (0.75 to 1.16)
1
0.98 (0.80 to 1.20)
1.49 (1.16 to 1.92)
Female:
1.37 (1.08 to 1.75)
1.10 (0.88 to 1.37)
1
1.23 (1.00 to 1.51)
1.62 (1.24 to 2.13)
Age, year of recruitment, sex, dialect,
education, body mass index, alcohol
drinking , years of smoking, dose of
smoking, moderate activity, energy
intake, dietary intakes of vegetables,
fruits, fiber, polyunsaturated fatty acids,
self-reported history of physician-
diagnosed hypertension, diabetes, stroke
and coronary heart disease, and history
of cancer reported by the nationwide
cancer registry
Anna Westerlund
et al, 2013,
Sweden47
National
March
Cohort Study
≥18
13.2
24-hour sleep
Questionnaire
Incidence
Both: 41192 (1685)
5
6
7
≥8
1.05 (0.80 to 1.37)
0.95 (0.79 to 1.14)
1
0.87 (0.72 to 1.04)
Age, sex, education, employment status,
smoking, alcohol, snoring, work
schedule, depressive symptoms, self-
rated health, physical activity, BMI,
diabetes, lipid disturbance, and
hypertension
Yeonju Kim et al,
2013, US17
Multiethnic
Cohort Study
45-75
12.9
24-hour sleep
Questionnaire
Mortality
Male: 61936 (627)
Female: 73749 (632)
Male:
≤5
6
7
8
≥9
Female:
≤5
6
7
8
≥9
Male:
1.14 (1.06 to 1.23)
1.10 (0.88 to 1.37)
1
1.13 (0.91 to 1.39)
1.35 (1.03 to 1.75)
Female:
1.16 (0.88 to 1.52)
0.99 (0.79 to 1.23)
1
1.07 (0.87 to 1.33)
1.39 (1.06 to 1.83)
5-year age groups at cohort entry, sex,
ethnicity, education, marital status,
history of hypertension or diabetes at
enrollment, alcohol consumption, energy
intake, body mass index, physical
activity, hours spent daily watching
television, and smoking history
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Masako Kakizki
et al, 2013,
Japan12
Ohsaki
Cohort Study
40-79
10.8
24-hour sleep
Questionnaire
Mortality
Both: 49256 (1165)
≤6
7
8
9
≥10
1.05 (0.84 to 1.30)
1
1.17 (0.99 to 1.39)
1.30 (1.06 to 1.60)
1.51 (1.24 to 1.85)
Age, sex, total caloric intake, body mass
index, marital status, level of education,
job status, history of myocardial
infarction, history of cancer, history of
stroke, history of hypertension, history
of diabetes mellitus, smoking status,
alcohol drinking, time spent walking,
perceived mental stress, self-rated
health, physical function
Anne von Ruesten
et al, 2012,
Germany55
European
Prospective
Investigation
into Cancer
and Nutrition
(EPIC)-
Potsdam
Study
35-65
7.8
24-hour sleep
Interview
Incidence
Both: 23620 (169)
<6
6-7
7-8
8-9
≥9
2.06 (1.18 to 3.59)
1.13 (0.72 to 1.77)
1
1.16 (0.77 to 1.73)
1.65 (1.00 to 2.73)
Sex, age, education, marital status,
living status, depression, body mass
index, insomnia, hypnotics use, total
sleep time, excessive daytime
sleepiness, pain, smoking, alcohol
drinking, snorers, diabetes mellitus,
hypertension, cardiovascular disease,
stroke, and gouty arthritis
Yuko Hamazaki
et al, 2011,
Japan50
35-54
14
24-hour sleep
Questionnaire
Incidence
Male: 2282 (30)
<6
6-6.9
7-7.9
≥8
1.84 (0.23 to 14.90)
0.96 (0.30 to 3.10)
1
2.25 (0.91 to 5.57)
Age, sex, education, employment status,
smoking, alcohol, snoring, work
schedule, depressive symptoms, self-
rated health, physical activity, BMI,
diabetes, lipid disturbance, and
hypertension
Yoko Amagai et
al, 2010, Japan51
Jichi Medical
School
Cohort Study
18-90
10.7
Nighttime
sleep
Interview
Incidence
Male: 4413 (207)
Female: 6954 (204)
Male:
<5.9
6.0–6.9
7.0–7.9
8.0–8.9
9.0
Female:
<5.9
6.0–6.9
7.0–7.9
8.0–8.9
9.0
Male:
2.00 (0.93 to 4.31)
1.13 (0.63 to 2.03)
1
1.03 (0.69 to 1.53)
1.39 (0.92 to 2.10)
Female:
0.97 (0.39 to 2.41)
0.68 (0.39 to 1.18)
1
0.86 (0.60 to 1.23)
1.29 (0.86 to 1.91)
Age, sex, educational attainment, body
mass index, cigarette smoking, alcohol
consumption, past history of
hypertension, type 2 diabetes, CVD and
metabolic syndrome
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Satoyo Ikehara et
al, 2009, Japan28
JACC Study
40-79
14.3
24-hour sleep
Questionnaire
Mortality
Male: 41489 (1038)
Female: 57145 (926)
Male:
<4
5
6
7
8
9
≥10
Female:
<4
5
6
7
8
9
≥10
Male:
1.56 (0.82 to 2.94)
0.85 (0.58 to 1.26)
0.95 (0.76 to 1.20)
1
1.11 (0.95 to 1.30)
1.14 (0.92 to 1.42)
1.66 (1.31 to 2.08)
Female:
1.07 (0.59 to 1.91)
0.99 (0.72 to 1.37)
0.93 (0.75 to 1.16)
1
1.24 (1.05 to 1.47)
1.29 (1.01 to 1.64)
1.69 (1.29 to 2.20)
Age, body mass index (quintiles),
history of hypertension, history of
diabetes, alcohol consumption, smoking,
education level, hours of exercise, hours
of walking, regular employment,
perceived mental stress, depressive
symptoms and frequency of fresh fish
intake
Jiu-Chiuan Chen
et al, 2008, US67
Women’s
Health
Initiative
Observationa
l Study
Cohort
50-79
7.5
Nighttime
sleep
Questionnaire
Incidence
Female: 93175
(1166)
≤6
7
8
≥9
1.14 (0.97 to 1.33)
1
1.24 (1.04 to 1.47)
1.70 (1.32 to 2.21)
Age, sex, total caloric intake, body mass
index in, marital status, level of
education, job status, history of
myocardial infarction, history of cancer,
history of stroke, history of
hypertension, history of diabetes
mellitus, smoking status, alcohol
drinking, time spent walking, perceived
mental stress, self-rated health, physical
function
Yoko Amagai et
al, 2004, Japan32
Jichi Medical
School
Cohort Study
19-93
8.2
Nighttime
sleep
Interview
Mortality
Male: 4419 (34)
Female: 6906 (29)
Male:
-5.9
6.0-6.9
7.0-7.9
8.0-8.9
9.0-
Female:
-5.9
6.0-6.9
7.0-7.9
8.0-8.9
9.0-
Male:
1.3 (0.2 to 11.0)
0.8 (0.2 to 3.9)
1
0.2 (0.1 to 0.8)
1.2 (0.5 to 3.0)
Female:
NA(n=0)
3.2 (1.0 to 10.5)
1
1.4 (0.4 to 4.3)
2.5 (0.8 to 8.2)
Age, systolic blood pressure, total
cholesterol, body mass index, smoking
habits, alcohol drinking habits,
education, and marital status
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Adnan I. Qureshi
et al, 1997, US60
First
National
Health and
Nutrition
Examination
Survey
Epidemiologi
c Follow-up
Study
32-74
10
Nighttime
sleep
Questionnaire
Incidence
Both: 7844 (285)
<6
6-8
>8
1.0 (0.7 to 1.5)
1
1.5 (1.1 to 2.0)
Age, body mass index, systolic blood
pressure, diastolic blood press, smoking
status, drinking habits and physical
activity
BMI; body mass index, CVD; cardiovascular disease
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Table S5. Study quality of studies included in the analysis of sleep duration and all-cause mortality
Author, publication year, country
Study
Selection
Comparability
Outcome
Total
Score
Nisha Aurora et al, 2016, US1
Sleep Heart Health Study
***
**
***
8
Wei-Ju Lee et al, 2016, Taiwan2
The Social Environment and Biomarkers of Aging Study
***
**
*
6
Xizhu Wang et al, 2016, China3
Kailuan study
***
**
*
6
Hui Cai et al, 2015, China4
Shanghai Women’s and Men’s Health Studies
***
**
***
8
Lisette A. Zuurbier et al, 2015, Netherlands5
Rotterdam Study
***
**
***
8
Martica H. Hall et al, 2015, US6
Health, Aging and Body Composition (Health ABC) Study
****
**
***
9
Naja Hulvej Rod et al, 2014, British7
British Whitehall II Prospective Cohort Study
***
**
***
8
Qian Xiao et al, 2014, US8
National Institutes of Health-AARP Diet and Health Study
**
**
**
6
Andrea Bellavia et al, 2014, Sweden9
Cohort of Swedish Men and the Swedish Mammography Cohort
***
**
***
8
Christopher A. Magee et al, 2013, Australia10
45 and Up Study
**
**
**
6
Garde AH et al, 2013, Denmark11
Copenhagen Male Study
**
**
***
7
Masako Kakizaki et al, 2013, Japan12
Ohsaki Cohort Study
**
**
***
7
Yohwan Yeo et al, 2013, Korea13
Korean Multi-center Cancer Cohort study
***
**
**
7
Hsi-Chung Chen et al, 2013, Taiwan14
Shih-Pai Sleep Study
***
**
**
7
Kyu-In Jung et al, 2013, US15
Rancho Bernardo Study
**
**
***
7
Lauren Hale et al, 2013, US16
Women’s Health Initiative (WHI) clinical trial (CT) and observational study (OS)
**
*
**
5
Yeonju Kim et al, 2013, US17
Multiethnic Cohort Study
***
**
**
7
Ying Li et al, 2013, Japan18
SAKU Cohort
**
**
**
6
Jiska Cohen-Mansfield et al, 2012, Israel19
Cross-Sectional and Longitudinal Aging Study
***
**
***
8
Chul Woo Rhee et al, 2012, Korea20
Seoul Male Cohort Study
**
**
**
6
Castro-Costa et al, 2011, Brasil21
Bambui Health and Ageing Study (BHAS)
***
**
***
8
Li Qiu et al, 2011, China22
Chinese Longitudinal Healthy Longevity Survey
***
**
**
7
Erkki Kronholm et al, 2011, Finland23
**
**
***
7
Arthur Eumann Mesas et al, 2010, Spain24
***
**
***
8
Kuo-Liong Chien et al, 2010, Taiwan25
Chin-shan Community Cardiovascular Cohort Study
***
**
***
8
Katie L. Stone et al, 2009, US26
Study of Osteoporotic Fractures Prospective Cohort Study
**
**
**
6
Etsuji Suzuki et al, 2009, Japan27
Shizuoka Study
**
**
***
7
Satoyo Ikehara et al, 2009, Japan28
JACC Study
***
**
**
7
James E. Gangwisch et al, 2008, US29
NHANES I Epidemiologic Follow-up Study
***
**
**
7
Christer Hublin et al, 2007, Finland30
Finnish Twin Cohort
*
**
**
5
Tzuo-Yun Lan et al, 2007, Taiwan31
Survey of Health and Living Status of the Elderly in Taiwan
***
**
***
8
Yoko Amagai et al, 2004, Japan32
Jichi Medical School Cohort Study
****
**
**
8
Sanjay R. Patel et al, 2003, US33
Nurses’ Health Study (NHS) Cohort
*
**
**
5
Genc Burazeri et al, 2003, Israel34
Kiryat Yovel Community Health Study
***
**
**
7
Aya Goto et al, 2003, Japan35
**
**
***
7
L. MALLON et al, 2002, Sweden36
**
**
**
6
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Daniel F. Kripke et al, 2002, US37
Cancer Prevention Study II
**
**
***
7
Pauline Heslop et al, 2002, British38
*
**
**
5
Masayo Kojima et al, 2000, Japan39
**
**
**
6
Catharine Gale et al, 1998, British40
***
**
***
8
Ana Ruigomez et al, 1995, Spain41
Health Interview Survey of Barcelona
***
**
*
6
Yoshitaka Tsubono et al, 1993, Japan42
National Collaborative Cohort Study
**
**
**
6
Roger Rumble et al, 1992, England43
Nottingham Longitudinal Study of Activity
**
*
***
6
Selection: 1) Representativeness of the exposed cohort; 2) Selection of the non-exposed cohort; 3) Ascertainment of exposure; 4) Demonstration that outcome of interest was not present at start of study (cardiovascular events);
Comparability: 1a) study controls for age (the most important factor); 1b) study controls for any additional factor;
Outcome: 1) Assessment of outcome; 2) Was follow-up long enough (≥5 years) for outcomes to occur; 3) Adequacy of follow up of cohorts (≥80%)
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Table S6. Study quality of studies included in the analysis of sleep duration and total CVD
Author, publication year, country
Study
Selection
Comparability
Outcome
Total
Score
Francesco Gianfagna et al, 2016, Italy44
MONICA Brianza and PAMELA
***
**
***
8
Hui Cai et al, 2015, China4
Shanghai Women’s and Men’s Health Studies
***
**
***
8
Catarina Canivet et al, 2014, Sweden45
Malmö Diet and Cancer Study
***
**
**
7
Qian Xiao et al, 2014, US8
National Institutes of Health-AARP Diet and Health Study
**
**
**
6
Naja Hulvej Rod et al, 2014, British7
British Whitehall II Prospective Cohort Study
***
**
***
8
Andrea Bellavia et al, 2014, Sweden9
Cohort of Swedish Men and the Swedish Mammography Cohort
***
**
***
8
Megan Sands-Lincoln et al, 2013, US46
Women’s Health Initiative Observational Study
***
**
**
7
Anna Westerlund et al, 2013, Sweden47
National March Cohort Study
***
**
**
7
Elizabeth G. Holliday et al, 2013, Australia48
45 and Up Study
***
**
**
7
Yeonju Kim et al, 2013, US17
Multiethnic Cohort Study
***
**
**
7
Hsi-Chung Chen et al, 2013, Taiwan14
Shih-Pai Sleep Study
***
**
**
7
Yohwan Yeo et al , 2013, Korea13
Korean Multi-center Cancer Cohort study
***
**
**
7
Masako Kakizki et al, 2013, Japan12
Ohsaki Cohort Study
**
**
***
7
Ying Li et al, 2013, Japan18
SAKU Cohort
**
**
**
6
Marieke P. Hoevenaar-Blom et al, 2011, Netherlands49
MORGEN Study
***
**
**
7
Yuko Hamazaki et al, 2011, Japan50
**
**
***
7
Erkki Kronholm et al, 2011, Finland23
**
**
***
7
Kuo-Liong Chien et al, 2010, Taiwan25
Chin-shan Community Cardiovascular Cohort study
***
**
***
8
Yoko Amagai et al, 2010, Japan51
Jichi Medical School Cohort Study
****
**
**
8
Katie L. Stone et al, 2009, US26
Study of Osteoporotic Fractures Prospective Cohort Study
**
**
**
6
Etsuji Suzuki et al, 2009, Japan27
Shizuoka Study
**
**
***
7
Satoyo Ikehara et al, 2009, Japan28
JACC Study
***
**
**
7
Tzuo-Yun Lan et al, 2007, Taiwan31
Survey of Health and Living Status of the Elderly in Taiwan
***
**
***
8
Sanjay R. Patel et al, 2004, US33
Nurses’ Health Study (NHS) Cohort
*
**
**
5
Genc Burazeri et al, 2003, Israel34
Kiryat Yovel Community Health Study
***
**
**
7
Pauline Heslop et al, 2002, British38
*
**
**
5
Selection: 1) Representativeness of the exposed cohort; 2) Selection of the non-exposed cohort; 3) Ascertainment of exposure; 4) Demonstration that outcome of interest was not present at start of study;
Comparability: 1a) study controls for age (the most important factor); 1b) study controls for any additional factor;
Outcome: 1) Assessment of outcome; 2) Was follow-up long enough (≥5 years) for outcomes to occur; 3) Adequacy of follow up of cohorts (≥80%)
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Table S7. Study quality of studies included in the analysis of sleep duration and CHD
Author, publication year, country
Study
Selection
Comparability
Outcome
Total
Score
Francesco Gianfagna et al, 2016, Italy44
MONICA Brianza and PAMELA Population-based Cohorts
***
**
***
8
Liangle Yang et al, 2016, China52
Dongfeng-Tongji Cohort Study
**
**
**
6
Xizhu Wang et al, 2016, China3
Kailuan Study
***
**
*
6
Linn B. Strand et al, 2016, Taiwan53
**
**
**
6
J. Liu et al, 2014, US54
Framingham Offspring Study
***
**
**
7
Megan Sands-Lincoln et al, 2013, US46
Women’s Health Initiative Observational Study
***
**
**
7
Lauren Hale et al, 2013, US16
Women’s Health Initiative (WHI) clinical trial (CT) and observational study (OS)
**
*
**
5
Yeonju Kim et al, 2013, US17
Multiethnic Cohort Study
***
**
**
7
Masako Kakizki et al, 2013, Japan12
Ohsaki Cohort Study
**
**
***
7
Garde AH et al, 2013, Denmark11
Copenhagen Male Study
**
**
***
7
Anna Westerlund et al, 2013, Sweden47
National March Cohort Study
***
**
**
7
Anne von Ruesten et al, 2012, Germany55
European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study
****
**
***
9
Marieke P. Hoevenaar-Blom et al, 2011, Netherlands49
MORGEN Study
***
**
**
7
Yuko Hamazaki et al, 2011, Japan50
**
**
***
7
Tarani Chandola et al, 2010, British56
British Whitehall II Prospective Cohort Study
***
**
**
7
Yoko Amagai et al, 2010, Japan51
Jichi Medical School Cohort Study
****
**
**
8
Satoyo Ikehara et al, 2009, Japan28
JACC Study
***
**
**
7
Anoop Shankar et al, 2008, Singapore57
Singapore Chinese Health Study
****
**
***
9
Christa Meisinger et al, 2007, Germany58
MONICA/KORA Augsburg Cohort Study
****
**
**
8
Najib T.Ayas et al, 2003, US59
Nurse's Health Study
**
**
**
6
L. MALLON et al, 2002, Sweden36
**
**
**
6
Adnan I. Qureshi et al, 1997, US60
First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study
***
**
**
7
Selection: 1) Representativeness of the exposed cohort; 2) Selection of the non-exposed cohort; 3) Ascertainment of exposure; 4) Demonstration that outcome of interest was not present at start of study;
Comparability: 1a) study controls for age (the most important factor); 1b) study controls for any additional factor;
Outcome: 1) Assessment of outcome; 2) Was follow-up long enough (≥5 years) for outcomes to occur; 3) Adequacy of follow up of cohorts (≥80%)
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Table S8. Study quality of studies included in the analysis of sleep duration and stroke
Author, publication year, country
Study
Selection
Comparability
Outcome
Total
Score
Qiaofeng Song et al, 2016, China61
The Kailuan Study
**
**
**
6
Toshiaki Kawachi et al, 2016, Japan62
Takayama Cohort Study
***
**
***
8
A. Katharina Helbig et al, 2015, Germany63
MONICA/KORA Augsburg Cohort Study
****
**
**
8
Yue Leng et al, 2015, British64
European Prospective Investigation of Cancer–Norfolk Cohort Study
***
**
**
7
Hui Cai et al, 2015, China4
Shanghai Women’s and Men’s Health Studies
***
**
***
8
Megan E. Ruiter Petrov et al, 2014, US65
Reasons for Geographic And Racial Differences in Stroke (REGARDS) Study
***
*
4
An Pan et al, 2014, Singapore66
Singapore Chinese Health Study
**
**
***
7
Anna Westerlund et al, 2013, Sweden47
National March Cohort Study
***
**
**
7
Yeonju Kim et al, 2013, US17
Multiethnic Cohort Study
***
**
**
7
Masako Kakizki et al, 2013, Japan12
Ohsaki Cohort Study
**
**
***
7
Anne von Ruesten et al, 2012, Germany55
European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study
****
**
***
9
Yuko Hamazaki et al, 2011, Japan50
**
**
***
7
Yoko Amagai et al, 2010, Japan51
Jichi Medical School Cohort Study
****
**
**
8
Satoyo Ikehara et al, 2009, Japan28
JACC Study
***
**
**
7
Jiu-Chiuan Chen et al, 2008, US67
Women’s Health Initiative Observational Study Cohort
***
**
**
7
Adnan I. Qureshi et al, 1997, US60
First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study
***
**
**
7
Selection: 1) Representativeness of the exposed cohort; 2) Selection of the non-exposed cohort; 3) Ascertainment of exposure; 4) Demonstration that outcome of interest was not present at start of study;
Comparability: 1a) study controls for age (the most important factor); 1b) study controls for any additional factor;
Outcome: 1) Assessment of outcome; 2) Was follow-up long enough (≥5 years) for outcomes to occur; 3) Adequacy of follow up of cohorts (≥80%)
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Table S9. Subgroup analyses of sleep duration and all-cause mortality, per hour per day
Short sleep
Long sleep
No
RR (95% CI)
Phet*
I²
Phet†
No
RR (95% CI)
Phet*
I²
Phet†
Total
32
1.06 (1.04 to 1.07)
0.00
58.0%
NC
37
1.13 (1.11 to 1.15)
0.00
76.5%
NC
Sex
Men
11
1.06 (1.05 to 1.08)
0.57
0.0%
0.57/0.97
13
1.10 (1.09 to 1.11)
0.54
0.0%
0.21/0.49
Women
13
1.05 (1.04 to 1.07)
0.30
14.9%
14
1.15 (1.11 to 1.18)
0.00
81.5%
Mix
14
1.06 (1.03 to 1.09)
0.00
64.2%
16
1.13 (1.10 to 1.16)
0.00
75.8%
Location
Asia
13
1.05 (1.02 to 1.09)
0.02
52.1%
0.05
18
1.15 (1.11 to 1.18)
0.00
70.9%
0.41
Europe
6
1.12 (1.09 to 1.15)
0.38
6.5%
7
1.14 (1.10 to 1.17)
0.22
27.9%
USA
11
1.04 (1.03 to 1.06)
0.05
45.2%
10
1.12 (1.09 to 1.15)
0.00
87.0%
Others
2
1.04 (0.99 to 1.09)
0.92
0.0%
2
1.13 (0.98 to 1.30)
0.00
70.7%
Duration of follow-up
<10 years
17
1.05 (1.03 to 1.07)
0.02
45.9%
0.40
20
1.13 (1.10 to 1.16)
0.00
73.9%
0.78
≥10 years
15
1.07 (1.04 to 1.09)
0.00
66.6%
17
1.13 (1.10 to 1.15)
0.00
75.1%
No of participants
<10000
15
1.05 (1.02 to 1.09)
0.55
0.0%
1.00
20
1.16 (1.13 to 1.19)
0.06
34.9%
0.05
≥10000
17
1.06 (1.04 to 1.07)
0.00
73.6%
17
1.13 (1.11 to 1.15)
0.00
77.5%
No of cases
<1000
13
1.07 (1.02 to 1.13)
0.65
0.0%
0.51
17
1.15 (1.11 to 1.19)
0.04
40.3%
0.31
≥1000
19
1.06 (1.04 to 1.07)
0.00
71.2%
20
1.12 (1.10 to 1.14)
0.00
75.5%
Sleep assessment
Self-report questionnaire
21
1.06 (1.04 to 1.08)
0.00
63.7%
0.29
23
1.12 (1.10 to 1.14)
0.00
78.7%
0.16
Interview
11
1.06 (1.02 to 1.11)
0.17
44.0%
14
1.16 (1.11 to 1.20)
0.00
71.0%
Sleep duration type
Nighttime sleep
21
1.06 (1.04 to 1.08)
0.00
53.3%
0.93
24
1.16 (1.13 to 1.18)
0.00
73.0%
0.01
24-hour sleep
11
1.06 (1.03 to 1.08)
0.00
64.4%
13
1.11 (1.10 to 1.13)
0.00
78.4%
Study quality score
<7
8
1.04 (1.01 to 1.07)
0.05
35.1%
0.30
8
1.14 (1.08 to 1.20)
0.01
60.5%
0.85
≥7
24
1.06 (1.05 to 1.08)
0.01
46.2%
29
1.13 (1.11 to 1.15)
0.00
78.8%
Adjustment for confounders
Age
Yes
32
1.06 (1.04 to 1.07)
0.00
58.0%
NC
37
1.13 (1.11 to 1.15)
0.00
76.5%
NC
No
0
0
Education
Yes
21
1.06 (1.04 to 1.08)
0.00
63.0%
0.81
20
1.12 (1.10 to 1.14)
0.00
59.4%
0.43
No
11
1.06 (1.03 to 1.09)
0.23
22.3%
17
1.14 (1.10 to 1.19)
0.00
82.6%
Hypertension, blood pressure
Yes
24
1.06 (1.05 to 1.07)
0.24
16.0%
0.37
28
1.13 (1.11 to 1.15)
0.00
72.7%
0.32
No
8
1.05 (1.02 to 1.10)
0.00
67.8%
9
1.12 (1.06 to 1.18)
0.00
83.1%
Yes
7
1.10 (1.06 to 1.15)
0.25
23.3%
0.02
7
1.15 (1.12 to 1.19)
0.83
0.0%
0.36
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Hypercholesterolemia, serum
cholesterol
No
25
1.05 (1.04 to 1.07)
0.00
47.9%
30
1.13 (1.11 to 1.15)
0.00
80.2%
Diabetes
Yes
18
1.06 (1.04 to 1.07)
0.41
3.9%
0.66
21
1.13 (1.11 to 1.15)
0.00
77.6%
0.96
No
14
1.07 (1.04 to 1.10)
0.00
68.9%
16
1.14 (1.10 to 1.18)
0.00
76.2%
Smoke
Yes
28
1.06 (1.05 to 1.08)
0.00
60.0%
0.15
31
1.13 (1.11 to 1.15)
0.00
77.3%
0.30
No
4
1.03 (0.97 to 1.03)
0.27
23.5%
6
1.10 (1.00 to 1.21)
0.00
67.7%
Alcohol
Yes
24
1.06 (1.04 to 1.08)
0.00
55.5%
0.93
26
1.13 (1.11 to 1.16)
0.00
77.5%
0.57
No
8
1.06 (1.03 to 1.08)
0.00
62.7%
11
1.12 (1.09 to 1.15)
0.00
67.8%
Physical activity
Yes
20
1.06 (1.04 to 1.08)
0.00
55.5%
0.97
23
1.13 (1.11 to 1.16)
0.00
79.4%
0.67
No
12
1.05 (1.03 to 1.07)
0.00
59.9%
14
1.12 (1.09 to 1.15)
0.00
63.6%
BMI
Yes
26
1.06 (1.04 to 1.08)
0.00
59.8%
0.84
28
1.13 (1.11 to 1.14)
0.00
67.4%
0.63
No
6
1.08 (1.01 to 1.15)
0.02
60.7%
9
1.13 (1.11 to 1.15)
0.00
81.8%
Sleep disorder
Yes
5
1.05 (1.03 to 1.07)
0.22
29.7%
0.52
5
1.12 (1.09 to 1.15)
0.01
68.4%
0.83
No
27
1.06 (1.04 to 1.08)
0.00
57.0%
32
1.13 (1.11 to 1.15)
0.00
76.7%
Depression
Yes
9
1.04 (1.02 to 1.06)
0.77
0.0%
0.11
11
1.15 (1.12 to 1.19)
0.00
64.6%
0.15
No
23
1.07 (1.05 to 1.09)
0.00
66.0%
26
1.12 (1.10 to 1.14)
0.00
79.4%
Sleeping pills
Yes
6
1.04 (0.99 to 1.09)
0.44
0.0%
0.64
8
1.18 (1.14 to 1.21)
0.26
20.9%
0.10
No
26
1.06 (1.04 to 1.08)
0.00
61.4%
29
1.20 (1.10 to 1.14)
0.00
68.8%
No denotes the number of studies.
Phet* for heterogeneity within each subgroup,
Phet† for heterogeneity between subgroups with meta-regression analysis,
NC = not calculable
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Table S10. Subgroup analyses of sleep duration and total cardiovascular disease, per hour per day
Short sleep
Long sleep
No
RR (95% CI)
Phet*
I²
Phet†
No
RR (95% CI)
Phet*
I²
Phet†
Total
21
1.06 (1.03 to 1.09)
0.00
52.0%
NC
23
1.12 (1.08 to 1.16)
0.00
75.3%
NC
Sex
Men
7
1.07 (1.01 to 1.13)
0.19
31.0%
0.57/0.63
7
1.11 (1.08 to 1.14)
0.53
0.0%
0.66/0.99
Women
8
1.07 (1.02 to 1.12)
0.06
48.7%
9
1.14 (1.08 to 1.19)
0.04
51.0%
Mix
8
1.05 (1.03 to 1.08)
0.00
63.2%
9
1.12 (1.04 to 1.20)
0.00
87.4%
Location
Asia
11
1.06 (1.01 to 1.11)
0.25
20.0%
0.34
13
1.16 (1.13 to 1.20)
0.24
19.7%
0.01
Europe
4
1.12 (1.01 to 1.23)
0.00
82.3%
4
1.06 (0.97 to 1.16)
0.01
75.2%
USA
5
1.04 (1.02 to 1.06)
0.24
27.6%
5
1.11 (1.05 to 1.17)
0.02
64.3%
Others
1
1.03 (0.96 to 1.10)
1
1.00 (0.96 to 1.03)
Duration of follow-up
<10 years
6
1.04 (0.99 to 1.09)
0.56
0.0%
0.75
9
1.17 (1.07 to 1.28)
0.00
85.1%
0.24
≥10 years
15
1.06 (1.03 to 1.09)
0.00
62.9%
14
1.10 (1.07 to 1.14)
0.00
60.1%
No of participants
<10000
7
1.12 (1.00 to 1.26)
0.13
39.1%
0.47
10
1.18 (1.12 to 1.24)
0.24
21.9%
0.08
≥10000
14
1.05 (1.03 to 1.08)
0.00
57.4%
13
1.10 (1.05 to 1.14)
0.00
80.8%
No of cases
<1000
8
1.11 (1.00 to 1.22)
0.19
30.5%
0.53
10
1.15 (1.10 to 1.21)
0.60
0.0%
0.22
≥1000
13
1.05 (1.03 to 1.08)
0.00
60.7%
13
1.10 (1.06 to 1.15)
0.00
84.5%
Sleep assessment
Self-report questionnaire
14
1.06 (1.03 to 1.09)
0.00
61.8%
0.95
15
1.11 (1.01 to 1.16)
0.00
82.6%
0.40
Interview
7
1.06 (0.98 to 1.14)
0.27
21.4%
8
1.15 (1.08 to 1.23)
0.45
0.0%
Sleep duration type
Nighttime sleep
10
1.04 (1.02 to 1.07)
0.18
28.7%
0.43
11
1.11 (1.04 to 1.18)
0.00
72.4%
0.71
24-hour sleep
11
1.08 (1.03 to 1.13)
0.00
61.4%
12
1.13 (1.09 to 1.17)
0.00
60.2%
Study quality score
<7
2
1.04 (1.02 to 1.06)
0.95
0.0%
0.58
1
1.21 (1.09 to 1.34)
0.33
≥7
19
1.07 (1.03 to 1.10)
0.00
56.1%
22
1.11 (1.07 to 1.15)
0.00
75.3%
Incidence or mortality
Incidence
7
1.02 (0.98 to 1.07)
0.20
30.0%
0.10
6
1.00 (0.97 to 1.03)
0.50
0.0%
0.00
Mortality
16
1.08 (1.04 to 1.11)
0.00
53.8%
19
1.15 (1.12 to 1.18)
0.01
46.3%
Adjustment for confounders
Age
Yes
21
1.06 (1.03 to 1.09)
0.00
52.0%
NC
23
1.12 (1.08 to 1.16)
0.00
75.3%
NC
No
0
0
Education
Yes
16
1.05 (1.02 to 1.08)
0.00
54.2%
0.36
16
1.10 (1.06 to 1.15)
0.00
80.1%
0.26
No
5
1.09 (1.03 to 1.15)
0.31
16.1%
7
1.15 (1.10 to 1.21)
0.18
32.0%
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Hypertension, blood
pressure
Yes
17
1.06 (1.03 to 1.09)
0.07
36.0%
0.77
18
1.12 (1.08 to 1.15)
0.00
57.1%
0.88
No
4
1.08 (1.00 to 1.16)
0.00
82.0%
5
1.12 (0.99 to 1.26)
0.00
89.8%
Hypercholesterolemia,
serum cholesterol
Yes
8
1.05 (1.00 to 1.11)
0.02
58.8%
0.69
7
1.06 (0.99 to 0.13)
0.02
60.4%
0.06
No
13
1.06 (1.03 to 1.10)
0.03
48.7%
16
1.14 (1.10 to 1.19)
0.00
77.6%
Diabetes
Yes
13
1.04 (1.01 to 1.07)
0.18
25.9%
0.29
14
1.12 (1.08 to 1.16)
0.00
61.1%
0.86
No
8
1.09 (1.03 to 1.14)
0.00
70.9%
9
1.20 (1.03 to 1.21)
0.00
83.3%
Smoke
Yes
21
1.06 (1.03 to 1.09)
0.00
52.0%
NC
23
1.12 (1.08 to 1.16)
0.00
75.3%
NC
No
0
0
Alcohol
Yes
19
1.06 (1.03 to 1.08)
0.00
53.2%
0.38
21
1.12 (1.08 to 1.16)
0.00
75.9%
0.90
No
2
1.10 (1.05 to 1.16)
0.10
0.0%
2
1.11 (0.96 to 1.29)
0.01
83.3%
Physical activity
Yes
14
1.05 (1.02 to 1.08)
0.00
58.6%
0.17
15
1.12 (1.08 to 1.17)
0.00
79.4%
0.76
No
7
1.10 (1.01 to 1.15)
0.50
0.0%
8
1.12 (1.03 to 1.22)
0.00
66.5%
BMI
Yes
21
1.06 (1.03 to 1.09)
0.00
52.0%
NC
23
1.12 (1.08 to 1.16)
0.00
75.3%
NC
No
0
0
Sleep disorder
Yes
1
1.01 (0.86 to 1.18)
0.64
1
1.51 (1.20 to 1.90)
0.03
No
20
1.06 (1.03 to 1.09)
0.00
54.2%
22
1.11 (1.07 to 1.15)
0.00
74.4%
Depression
Yes
7
1.02 (0.99 to 1.04)
0.81
0.0%
0.09
9
1.15 (1.10 to 1.21)
0.00
61.3%
0.16
No
14
1.08 (1.04 to 1.12)
0.00
60.9%
14
1.10 (1.05 to 1.15)
0.00
78.4%
Sleeping pills
Yes
1
1.01 (0.86 to 1.18)
0.64
1
1.51 (1.20 to 1.90)
0.03
No
20
1.06 (1.03 to 1.09)
0.00
54.2%
22
1.12 (1.07 to 1.15)
0.00
74.4%
No denotes the number of studies.
Phet* for heterogeneity within each subgroup,
Phet† for heterogeneity between subgroups with meta-regression analysis,
NC = not calculable
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Table S11. Subgroup analyses of sleep duration and coronary heart disease, per hour per day
Short sleep
Long sleep
No
RR (95% CI)
Phet*
I²
Phet†
No
RR (95% CI)
Phet*
I²
Phet†
Total
18
1.07 (1.03 to 1.12)
0.00
59.3%
NC
16
1.05 (1.00 to 1.10)
0.00
64.2%
NC
Sex
Men
7
1.08 (0.98 to 1.19)
0.01
66.1%
0.23/0.60
5
1.07 (0.95 to 1.20)
0.00
75.8%
0.23/0.58
Women
9
1.10 (1.03 to 1.18)
0.01
63.6%
7
1.09 (1.03 to 1.16)
0.17
33.8%
Mix
6
1.07 (0.99 to 1.15)
0.01
68.1%
6
1.04 (0.93 to 1.17)
0.00
84.6%
Location
Asia
8
1.13 (1.00 to 1.27)
0.00
73.6%
0.36
8
1.09 (1.02 to 1.18)
0.01
63.3%
0.02
Europe
5
1.04 (0.98 to 1.09)
0.48
0.0%
4
0.89 (0.82 to 0.97)
0.94
0.0%
USA
5
1.05 (1.00 to 1.09)
0.23
28.1%
4
1.07 (1.03 to 1.11)
0.35
9.0%
Duration of follow-up
<10 years
3
1.03 (0.97 to 1.09)
0.48
0.0%
0.38
3
1.03 (0.95 to 1.11)
0.30
18.0%
0.48
≥10 years
15
1.09 (1.03 to 1.14)
0.00
64.8%
13
1.06 (1.00 to 1.12)
0.00
69.0%
No of participants
<10000
7
1.08 (0.94 to 1.25)
0.07
48.1%
0.65
4
0.92 (0.81 to 1.06)
0.98
0.0%
0.15
≥10000
11
1.08 (1.03 to 1.13)
0.00
66.1%
12
1.06 (1.01 to 1.12)
0.00
70.4%
No of cases
<500
9
1.12 (0.97 to 1.30)
0.01
59.2%
0.74
7
1.00 (0.92 to 1.08)
0.52
0.0%
0.18
≥500
9
1.07 (1.02 to 1.11)
0.01
62.9%
9
1.07 (1.01 to 1.13)
0.00
76.2%
Sleep assessment
Self-report questionnaire
12
1.05 (1.01 to 1.09)
0.04
45.9%
0.05
10
1.05 (1.01 to 1.09)
0.03
50.9%
0.98
Interview
6
1.17 (1.02 to 1.35)
0.14
39.9%
6
1.00 (0.83 to 1.21)
0.00
75.3%
Sleep duration type
Nighttime sleep
11
1.06 (1.00 to 1.12)
0.00
63.9%
0.48
9
1.06 (0.98 to 1.14)
0.00
67.5%
0.82
24-hour sleep
7
1.10 (1.02 to 1.18)
0.10
43.9%
7
1.04 (0.97 to 1.11)
0.01
64.0%
Study quality score
<7
4
1.03 (0.97 to 1.10)
0.32
14.4%
0.29
4
1.08 (1.04 to 1.12)
0.39
1.4%
0.54
≥7
14
1.09 (1.03 to 1.16)
0.00
65.7%
12
1.03 (0.96 to 1.11)
0.00
71.2%
Incidence or mortality
Incidence
11
1.04 (1.00 to 1.10)
0.15
30.8%
0.42
9
1.00 (0.94 to 1.06)
0.04
50.5%
0.03
Mortality
8
1.10 (1.02 to 1.17)
0.00
66.3%
8
1.12 (1.05 to 1.19)
0.01
62.4%
Adjustment for confounders
Age
Yes
18
1.07 (1.03 to 1.12)
0.00
59.3%
NC
16
1.05 (1.00 to 1.10)
0.00
64.2%
NC
No
0
0
Education
Yes
12
1.07 (1.01 to 1.12)
0.00
66.4%
0.69
12
1.05 (1.00 to 1.11)
0.00
71.5%
0.69
No
6
1.04 (0.99 to 1.24)
0.11
44.6%
4
1.06 (0.97 to 1.15)
0.35
8.2%
Yes
16
1.05 (1.01 to 1.10)
0.03
44.7%
0.03
14
1.04 (1.00 to 1.08)
0.05
41.6%
0.13
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Hypertension, blood
pressure
No
2
1.22 (1.12 to 1.32)
0.33
0.0%
2
1.10 (0.78 to 1.54)
0.00
87.0%
Hypercholesterolemia,
serum cholesterol
Yes
12
1.04 (1.00 to 1.08)
0.18
26.5%
0.17
10
1.00 (0.94 to 1.06)
0.05
46.0%
0.02
No
6
1.10 (1.01 to 1.20)
0.00
69.7%
6
1.12 (1.05 to 1.19)
0.01
66.1%
Diabetes
Yes
14
1.05 (1.01 to 1.09)
0.04
43.6%
0.01
12
1.04 (1.00 to 1.09)
0.03
49.0%
0.29
No
4
1.22 (1.11 to 1.34)
0.37
5.2%
4
1.04 (0.82 to 1.33)
0.01
71.7%
Smoke
Yes
18
1.07 (1.03 to 1.12)
0.00
59.3%
NC
16
1.05 (1.00 to 1.10)
0.00
64.2%
NC
No
0
0
Alcohol
Yes
18
1.07 (1.03 to 1.12)
0.00
59.3%
NC
16
1.05 (1.00 to 1.10)
0.00
64.2%
NC
No
0
0
Physical activity
Yes
16
1.07 (1.02 to 1.12)
0.00
60.3%
0.19
13
1.07 (1.02 to 1.12)
0.00
58.6%
0.03
No
2
1.52 (0.92 to 2.50)
0.25
23.0%
3
0.88 (0.79 to 0.98)
0.83
0.0%
BMI
Yes
17
1.08 (1.03 to 1.13)
0.00
59.9%
0.27
15
1.05 (1.00 to 1.11)
0.00
70.0%
0.49
No
1
0.95 (0.81 to 1.10)
1
0.95 (0.77 to 1.18)
Sleep disorder
Yes
1
1.09 (0.86 to 1.38)
0.94
1
0.91 (0.72 to 1.14)
0.33
No
17
1.07 (1.02 to 1.12)
0.00
61.6%
15
1.06 (1.01 to 1.11)
0.00
65.0%
Depression
Yes
6
1.06 (0.98 to 1.14)
0.03
61.0%
0.71
4
1.06 (1.00 to 1.11)
0.31
15.6%
0.80
No
12
1.08 (1.02 to 1.15)
0.00
57.4%
12
1.04 (0.97 to 1.11)
0.00
71.1%
Sleeping pills
Yes
1
1.04 (0.97 to 1.11)
0.72
0
NC
No
17
1.08 (1.02 to 1.13)
0.00
61.6%
16
1.05 (1.00 to 1.10)
0.00
64.2%
No denotes the number of studies.
Phet* for heterogeneity within each subgroup,
Phet† for heterogeneity between subgroups with meta-regression analysis,
NC = not calculable
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Table S12. Subgroup analyses of sleep duration and stroke, per hour per day
Short sleep
Long sleep
No
RR (95% CI)
Phet*
I²
Phet†
No
RR (95% CI)
Phet*
I²
Phet†
Total
14
1.05 (1.01 to 1.09)
0.55
0.0%
NC
15
1.18 (1.14 to 1.21)
0.40
4.9%
NC
Sex
Men
6
1.05 (0.98 to 1.11)
0.79
0.0%
0.53/0.63
6
1.14 (1.09 to 1.19)
0.94
0.0%
0.14/0.88
Women
5
1.05 (0.97 to 1.13)
0.26
24.6%
7
1.20 (1.12 to 1.28)
0.07
48.7%
Mix
5
1.08 (1.00 to 1.13)
0.18
35.5%
6
1.20 (1.15 to 1.26)
0.36
9.4%
Location
Asia
7
1.05 (0.99 to 1.10)
0.47
0.0%
0.71
8
1.18 (1.14 to 1.22)
0.43
0.5%
0.13
Europe
4
1.06 (0.96 to 1.16)
0.18
38.7%
3
1.09 (0.99 to 1.21)
0.28
21.6%
USA
3
1.07 (0.98 to 1.17)
0.60
0.0%
4
1.20 (1.20 to 1.29)
0.58
0.0%
Duration of follow-up
<10 years
3
1.15 (0.98 to 1.35)
0.12
53.8%
0.36
4
1.28 (1.20 to 1.37)
0.92
0.0%
0.01
≥10 years
11
1.04 (1.00 to 1.09)
1.09
0.0%
11
1.15 (1.12 to 1.19)
0.83
0.0%
No of participants
<10000
6
1.06 (0.98 to 1.16)
0.49
0.0%
0.75
5
1.10 (1.02 to 1.18)
0.69
0.0%
0.08
≥10000
8
1.05 (1.00 to 1.09)
0.41
2.4%
10
1.19 (1.15 to 1.22)
0.45
0.0%
No of cases
<500
6
1.13 (0.98 to 1.30)
0.20
32.0%
0.30
4
1.09 (1.00 to 1.20)
0.53
0.0%
0.16
≥500
8
1.04 (1.00 to 1.09)
0.87
0.0%
11
1.18 (1.15 to 1.22)
0.42
2.1%
Sleep assessment
Self-report questionnaire
9
1.05 (1.00 to 1.09)
0.82
0.0%
0.57
10
1.19 (1.15 to 1.22)
0.47
0.0%
0.11
Interview
5
1.09 (0.96 to 1.24)
0.14
42.6%
5
1.10 (1.03 to 1.19)
0.55
0.0%
Sleep duration type
Nighttime sleep
3
1.13 (0.90 to 1.42)
0.20
37.8%
0.35
5
1.22 (1.13 to 1.30)
0.73
0.0%
0.35
24-hour sleep
11
1.05 (1.01 to 1.09)
1.09
0.0%
10
1.17 (1.13 to 1.21)
0.24
22.6%
Study quality score
<7
1
1.19 (0.95 to 1.49)
0.30
1
1.19 (0.95 to 1.50)
0.92
≥7
13
1.05 (1.01 to 1.09)
0.56
0.0%
14
1.18 (1.14 to 1.21)
0.33
11.6%
Incidence or mortality
Incidence
8
1.07 (0.99 to 1.16)
0.25
22.6%
0.86
7
1.15 (1.08 to 1.24)
0.26
22.0%
0.60
Mortality
10
1.05 (1.01 to 1.10)
0.66
0.0%
12
1.18 (1.14 to 1.21)
0.50
0.0%
Adjustment for confounders
Age
Yes
14
1.05 (1.01 to 1.09)
0.55
0.0%
NC
15
1.18 (1.14 to 1.21)
0.40
4.9%
NC
No
0
0
Education
Yes
11
1.05 (1.01 to 1.09)
0.56
0.0%
0.76
12
1.17 (1.14 to 1.21)
0.37
7.8%
0.41
No
3
1.09 (0.79 to 1.50)
0.23
32.7%
3
1.22 (1.12 to 1.34)
0.37
0.0%
Yes
11
1.04 (1.00 to 1.09)
0.77
0.0%
0.36
12
1.16 (1.13 to 1.20)
0.63
0.0%
0.04
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Hypertension, blood
pressure
No
3
1.15 (0.98 to 1.35)
0.16
53.8%
3
1.28 (1.19 to 1.38)
0.78
0.0%
Hypercholesterolemia,
serum cholesterol
Yes
7
1.06 (0.97 to 1.16)
0.34
24.9%
0.96
6
1.15 (1.06 to 1.25)
0.18
34.5%
0.52
No
7
1.05 (1.00 to 1.10)
0.71
0.0%
9
1.18 (1.15 to 1.22)
0.57
0.0%
Diabetes
Yes
9
1.04 (1.00 to 1.09)
0.90
0.0%
0.34
10
1.16 (1.13 to 1.20)
0.48
0.0%
0.09
No
5
1.32 (0.98 to 1.31)
1.22
45.0%
5
1.25 (1.16 to 1.33)
0.58
0.0%
Smoke
Yes
13
1.05 (1.01 to 1.09)
0.56
0.0%
0.30
14
1.18 (1.14 to 1.21)
0.33
11.6%
0.92
No
1
1.19 (0.95 to 1.49)
1
1.19 (0.95 to 1.49)
Alcohol
Yes
13
1.05 (1.01 to 1.09)
0.56
0.0%
0.30
13
1.17 (1.14 to 1.20)
0.42
2.6%
0.18
No
1
1.19 (0.95 to 1.49)
2
1.26 (1.14 to 1.40)
0.52
0.0%
Physical activity
Yes
8
1.05 (0.99 to 1.10)
0.65
0.0%
0.74
9
1.18 (1.12 to 1.24)
0.10
40.1%
0.80
No
6
1.06 (0.98 to 1.14)
0.25
24.0%
6
1.17 (1.12 to 1.22)
0.94
0.0%
BMI
Yes
13
1.05 (1.01 to 1.09)
0.56
0.0%
0.30
14
1.18 (1.14 to 1.21)
0.33
11.6%
0.92
No
1
1.19 (0.95 to 1.49)
1
1.19 (0.95 to 1.47)
Sleep disorder
Yes
1
1.37 (1.05 to 1.77)
0.07
1
1.26 (0.99 to 1.60)
0.58
No
13
1.05 (1.00 to 1.09)
0.80
0.0%
14
1.18 (1.14 to 1.21)
0.35
9.7%
Depression
Yes
3
1.00 (0.93 to 1.07)
0.99
0.0%
0.11
3
1.18 (1.12 to 1.25)
0.30
25.9%
0.77
No
11
1.07 (1.03 to 1.12)
0.55
0.0%
12
1.17 (1.13 to 1.22)
0.37
8.2%
Sleeping pills
Yes
1
1.00 (0.89 to 1.12)
0.40
1
1.26 (0.99 to 1.60)
0.58
No
13
1.06 (1.02 to 1.10)
0.53
0.0%
14
1.18 (1.14 to 1.21)
0.35
9.7%
No denotes the number of studies.
Phet* for heterogeneity within each subgroup,
Phet† for heterogeneity between subgroups with meta-regression analysis,
NC = not calculable
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Figure S1. Sleep duration and all-cause mortality, shortest and longest vs.
reference analysis
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Figure S2. Sleep duration and total cardiovascular disease, shortest and longest vs.
reference analysis
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Figure S3. Sleep duration and coronary heart disease, shortest and longest vs.
reference analysis
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Figure S4. Sleep duration and stroke, shortest and longest vs. reference analysis
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Figure S5. Trim-and-Fill correction for publication bias for total cardiovascular
disease, longest vs. reference analysis
Figure S6. Trim-and-Fill correction for publication bias for all-cause mortality,
dose-response analysis for short sleep
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Figure S7. Non-linear dose-response analysis of sleep duration and all-cause
mortality by nighttime sleep duration (A) and 24-hour sleep duration (B)
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Figure S8. Non-linear dose-response analysis of sleep duration and total
cardiovascular disease by incidence (A) and mortality (B)
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Figure S9. Non-linear dose-response analysis of sleep duration and total
cardiovascular disease by Asia (A), Europe (B) and US (C).
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Figure S10. Non-linear dose-response analysis of sleep duration and coronary
heart disease by incidence (A) and mortality (B)
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Figure S11. Non-linear dose-response analysis of sleep duration and stroke by
follow-up duration <10 years (A), follow-up duration ≥10 years (B)
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Figure S12. Sensitive analysis of stroke and sleep duration, shortest vs. reference
analysis
Figure S13. Sensitive analysis of stroke and sleep duration after excluding the
study of Kawachi (2016), shortest vs. reference analysis
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Supplemental References:
1. Aurora RN, Kim JS, Crainiceanu C, O'Hearn D, Punjabi NM. Habitual sleep duration and all-cause
mortality in a general community sample. Sleep. 2016;39:1903-1909.
2. Lee WJ, Peng LN, Liang CK, Chiou ST, Chen LK. Long sleep duration, independent of frailty and
chronic inflammation, was associated with higher mortality: A national population-based study.
Geriatrics & gerontology international. 2016 Sep 29. doi: 10.1111/ggi.12899. [Epub ahead of print].
3. Wang X, Liu X, Song Q, Wu S. Sleep duration and risk of myocardial infarction and all-cause death
in a chinese population: The kailuan study. Sleep medicine. 2016;19:13-16
4. Cai H, Shu XO, Xiang YB, Yang G, Li H, Ji BT, Gao J, Gao YT, Zheng W. Sleep duration and mortality:
A prospective study of 113 138 middle-aged and elderly chinese men and women. Sleep. 2015;38:529-
536
5. Zuurbier LA, Luik AI, Hofman A, Franco OH, Van Someren EJ, Tiemeier H. Fragmentation and
stability of circadian activity rhythms predict mortality: The rotterdam study. American journal of
epidemiology. 2015;181:54-63
6. Hall MH, Smagula SF, Boudreau RM, Ayonayon HN, Goldman SE, Harris TB, Naydeck BL, Rubin
SM, Samuelsson L, Satterfield S, Stone KL, Visser M, Newman AB. Association between sleep duration
and mortality is mediated by markers of inflammation and health in older adults: The health, aging
and body composition study. Sleep. 2015;38:189-195
7. Rod NH, Kumari M, Lange T, Kivimaki M, Shipley M, Ferrie J. The joint effect of sleep duration and
disturbed sleep on cause-specific mortality: Results from the whitehall ii cohort study. PloS one.
2014;9:e91965
8. Xiao Q, Keadle SK, Hollenbeck AR, Matthews CE. Sleep duration and total and cause-specific
mortality in a large us cohort: Interrelationships with physical activity, sedentary behavior, and body
mass index. American journal of epidemiology. 2014;180:997-1006
9. Bellavia A, Akerstedt T, Bottai M, Wolk A, Orsini N. Sleep duration and survival percentiles across
categories of physical activity. American journal of epidemiology. 2014;179:484-491
10. Magee CA, Holliday EG, Attia J, Kritharides L, Banks E. Investigation of the relationship between
sleep duration, all-cause mortality, and preexisting disease. Sleep medicine. 2013;14:591-596
11. Garde AH, Hansen AM, Holtermann A, Gyntelberg F, Suadicani P. Sleep duration and ischemic
heart disease and all-cause mortality: Prospective cohort study on effects of tranquilizers/hypnotics
and perceived stress. Scandinavian journal of work, environment & health. 2013;39:550-558
12. Kakizaki M, Kuriyama S, Nakaya N, Sone T, Nagai M, Sugawara Y, Hozawa A, Fukudo S, Tsuji I. Long
sleep duration and cause-specific mortality according to physical function and self-rated health: The
ohsaki cohort study. Journal of sleep research. 2013;22:209-216
13. Yeo Y, Ma SH, Park SK, Chang SH, Shin HR, Kang D, Yoo KY. A prospective cohort study on the
relationship of sleep duration with all-cause and disease-specific mortality in the korean multi-center
cancer cohort study. Journal of preventive medicine and public health = Yebang Uihakhoe chi.
2013;46:271-281
14. Chen HC, Su TP, Chou P. A nine-year follow-up study of sleep patterns and mortality in
community-dwelling older adults in taiwan. Sleep. 2013;36:1187-1198
15. Jung KI, Song CH, Ancoli-Israel S, Barrett-Connor E. Gender differences in nighttime sleep and
daytime napping as predictors of mortality in older adults: The rancho bernardo study. Sleep medicine.
2013;14:12-19
by guest on September 15, 2017http://jaha.ahajournals.org/Downloaded from

16. Hale L, Parente V, Dowd JB, Sands M, Berger JS, Song Y, Martin LW, Allison MA. Fibrinogen may
mediate the association between long sleep duration and coronary heart disease. Journal of sleep
research. 2013;22:305-314
17. Kim Y, Wilkens LR, Schembre SM, Henderson BE, Kolonel LN, Goodman MT. Insufficient and
excessive amounts of sleep increase the risk of premature death from cardiovascular and other
diseases: The multiethnic cohort study. Preventive medicine. 2013;57:377-385
18. Li Y, Sato Y, Yamaguchi N. Potential biochemical pathways for the relationship between sleep
duration and mortality. Sleep medicine. 2013;14:98-104
19. Cohen-Mansfield J, Perach R. Sleep duration, nap habits, and mortality in older persons. Sleep.
2012;35:1003-1009
20. Rhee CW, Kim JY, Park BJ, Li ZM, Ahn YO. Impact of individual and combined health behaviors on
all causes of premature mortality among middle aged men in korea: The seoul male cohort study.
Journal of preventive medicine and public health = Yebang Uihakhoe chi. 2012;45:14-20
21. Castro-Costa E, Dewey ME, Ferri CP, Uchoa E, Firmo JO, Rocha FL, Prince M, Lima-Costa MF,
Stewart R. Association between sleep duration and all-cause mortality in old age: 9-year follow-up of
the bambui cohort study, brazil. Journal of sleep research. 2011;20:303-310
22. Qiu L, Sautter J, Liu Y, Gu D. Age and gender differences in linkages of sleep with subsequent
mortality and health among very old chinese. Sleep medicine. 2011;12:1008-1017
23. Kronholm E, Laatikainen T, Peltonen M, Sippola R, Partonen T. Self-reported sleep duration, all-
cause mortality, cardiovascular mortality and morbidity in finland. Sleep medicine. 2011;12:215-221
24. Mesas AE, Lopez-Garcia E, Leon-Munoz LM, Guallar-Castillon P, Rodriguez-Artalejo F. Sleep
duration and mortality according to health status in older adults. Journal of the American Geriatrics
Society. 2010;58:1870-1877
25. Chien KL, Chen PC, Hsu HC, Su TC, Sung FC, Chen MF, Lee YT. Habitual sleep duration and
insomnia and the risk of cardiovascular events and all-cause death: Report from a community-based
cohort. Sleep. 2010;33:177-184
26. Stone KL, Ewing SK, Ancoli-Israel S, Ensrud KE, Redline S, Bauer DC, Cauley JA, Hillier TA,
Cummings SR. Self-reported sleep and nap habits and risk of mortality in a large cohort of older
women. Journal of the American Geriatrics Society. 2009;57:604-611
27. Suzuki E, Yorifuji T, Ueshima K, Takao S, Sugiyama M, Ohta T, Ishikawa-Takata K, Doi H. Sleep
duration, sleep quality and cardiovascular disease mortality among the elderly: A population-based
cohort study. Preventive medicine. 2009;49:135-141
28. Ikehara S, Iso H, Date C, Kikuchi S, Watanabe Y, Wada Y, Inaba Y, Tamakoshi A. Association of sleep
duration with mortality from cardiovascular disease and other causes for japanese men and women:
The jacc study. Sleep. 2009;32:295-301
29. Gangwisch JE, Heymsfield SB, Boden-Albala B, Buijs RM, Kreier F, Opler MG, Pickering TG, Rundle
AG, Zammit GK, Malaspina D. Sleep duration associated with mortality in elderly, but not middle-aged,
adults in a large us sample. Sleep. 2008;31:1087-1096
30. Hublin C, Partinen M, Koskenvuo M, Kaprio J. Sleep and mortality: A population-based 22-year
follow-up study. Sleep. 2007;30:1245-1253
31. Lan TY, Lan TH, Wen CP, Lin YH, Chuang YL. Nighttime sleep, chinese afternoon nap, and mortality
in the elderly. Sleep. 2007;30:1105-1110
32. Amagai Y, Ishikawa S, Gotoh T, Doi Y, Kayaba K, Nakamura Y, Kajii E. Sleep duration and mortality
in japan: The jichi medical school cohort study. Journal of epidemiology / Japan Epidemiological
by guest on September 15, 2017http://jaha.ahajournals.org/Downloaded from

Association. 2004;14:124-128
33. Patel SR, Ayas NT, Malhotra MR, White DP, Schernhammer ES, Speizer FE, Stampfer MJ, Hu FB. A
prospective study of sleep duration and mortality risk in women. Sleep. 2004;27:440-444
34. Burazeri G, Gofin J, Kark JD. Over 8 hours of sleep--marker of increased mortality in
mediterranean population: Follow-up population study. Croatian medical journal. 2003;44:193-198
35. Goto A, Yasumura S, Nishise Y, Sakihara S. Association of health behavior and social role with
total mortality among japanese elders in okinawa, japan. Aging - Clinical and Experimental Research.
2003;15:443-450
36. Mallon L, Broman JE, Hetta J. Sleep complaints predict coronary artery disease mortality in
males: A 12-year follow-up study of a middle-aged swedish population. Journal of internal medicine.
2002;251:207-216
37. Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR. Mortality associated with sleep
duration and insomnia. Arch Gen Psychiatry. 2002;59:131-136
38. Heslop P, Smith GD, Metcalfe C, Macleod J, Hart C. Sleep duration and mortality: The effect of
short or long sleep duration on cardiovascular and all-cause mortality in working men and women.
Sleep medicine. 2002;3:305-314
39. Kojima M, Wakai K, Kawamura T, Tamakoshi A, Aoki R, Lin Y, Nakayama T, Horibe H, Aoki N, Ohno
Y. Sleep patterns and total mortality: A 12-year follow-up study in japan. Journal of epidemiology /
Japan Epidemiological Association. 2000;10:87-93
40. Gale C, Martyn C. Larks and owls and health, wealth, and wisdom. BMJ (Clinical research ed.).
1998;317:1675-1677
41. Ruigomez A, Alonso J, Anto JM. Relationship of health behaviours to five-year mortality in an
elderly cohort. Age and Ageing. 1995;24:113-119
42. Tsubono Y, Fukao A, Hisamichi S. Health practices and mortality in a rural japanese population.
Tohoku J Exp Med. 1993;171:339-348
43. Rumble R, Morgan K. Hypnotics, sleep, and mortality in elderly people. Journal of the American
Geriatrics Society. 1992;40:787-791
44. Gianfagna F, Veronesi G, Bertu L, Cesana G, Grassi G, Stranges S, Callegari C, Ferrario MM.
Influence of sleep disturbances on age at onset and long-term incidence of major cardiovascular
events: The monica-brianza and pamela cohort studies. Sleep medicine. 2016;21:126-132
45. Canivet C, Nilsson PM, Lindeberg SI, Karasek R, Östergren PO. Insomnia increases risk for
cardiovascular events in women and in men with low socioeconomic status: A longitudinal, register-
based study. Journal of psychosomatic research. 2014;76:292-299
46. Sands-Lincoln M, Loucks EB, Lu B, Carskadon MA, Sharkey K, Stefanick ML, Ockene J, Shah N,
Hairston KG, Robinson JG, Limacher M, Hale L, Eaton CB. Sleep duration, insomnia, and coronary heart
disease among postmenopausal women in the women's health initiative. Journal of women's health
(2002). 2013;22:477-486
47. Westerlund A, Bellocco R, Sundstrom J, Adami HO, Akerstedt T, Trolle Lagerros Y. Sleep
characteristics and cardiovascular events in a large swedish cohort. European journal of epidemiology.
2013;28:463-473
48. Holliday EG, Magee CA, Kritharides L, Banks E, Attia J. Short sleep duration is associated with risk
of future diabetes but not cardiovascular disease: A prospective study and meta-analysis. PloS one.
2013;8:e82305
49. Hoevenaar-Blom MP, Spijkerman AM, Kromhout D, van den Berg JF, Verschuren WM. Sleep
by guest on September 15, 2017http://jaha.ahajournals.org/Downloaded from

duration and sleep quality in relation to 12-year cardiovascular disease incidence: The morgen study.
Sleep. 2011;34:1487-1492
50. Hamazaki Y, Morikawa Y, Nakamura K, Sakurai M, Miura K, Ishizaki M, Kido T, Naruse Y, Suwazono
Y, Nakagawa H. The effects of sleep duration on the incidence of cardiovascular events among middle-
aged male workers in japan. Scandinavian journal of work, environment & health. 2011;37:411-417
51. Amagai Y, Ishikawa S, Gotoh T, Kayaba K, Nakamura Y, Kajii E. Sleep duration and incidence of
cardiovascular events in a japanese population: The jichi medical school cohort study. Journal of
epidemiology / Japan Epidemiological Association. 2010;20:106-110
52. Yang L, Yang H, He M, Pan A, Li X, Min X, Zhang C, Xu C, Zhu X, Yuan J, Wei S, Miao X, Hu FB, Wu T,
Zhang X. Longer sleep duration and midday napping are associated with a higher risk of chd incidence
in middle-aged and older chinese: The dongfeng-tongji cohort study. Sleep. 2016;39:645-652
53. Strand LB, Tsai MK, Gunnell D, Janszky I, Wen CP, Chang SS. Self-reported sleep duration and
coronary heart disease mortality: A large cohort study of 400,000 taiwanese adults. International
journal of cardiology. 2016;207:246-251
54. Liu J, Yuen J, Kang S. Sleep duration, c-reactive protein and risk of incident coronary heart
disease--results from the framingham offspring study. Nutrition, metabolism, and cardiovascular
diseases : NMCD. 2014;24:600-605
55. von Ruesten A, Weikert C, Fietze I, Boeing H. Association of sleep duration with chronic diseases
in the european prospective investigation into cancer and nutrition (epic)-potsdam study. PloS one.
2012;7:e30972
56. Chandola T, Ferrie JE, Perski A, Akbaraly T, Marmot MG. The effect of short sleep duration on
coronary heart disease risk is greatest among those with sleep disturbance: A prospective study from
the whitehall ii cohort. Sleep. 2010;33:739-744
57. Shankar A, Koh WP, Yuan JM, Lee HP, Yu MC. Sleep duration and coronary heart disease mortality
among chinese adults in singapore: A population-based cohort study. American journal of
epidemiology. 2008;168:1367-1373
58. Meisinger C, Heier M, Lowel H, Schneider A, Doring A. Sleep duration and sleep complaints and
risk of myocardial infarction in middle-aged men and women from the general population: The
monica/kora augsburg cohort study. Sleep. 2007;30:1121-1127
59. Ayas NT, White DP, Manson JE, Stampfer MJ, Speizer FE, Malhotra A, Hu FB. A prospective study
of sleep duration and coronary heart disease in women. Archives of internal medicine. 2003;163:205-
209
60. Qureshi AI, Giles WH, Croft JB, Bliwise DL. Habitual sleep patterns and risk for stroke and
coronary heart disease: A 10-year follow-up from nhanes i. Neurology. 1997;48:904-911
61. Song Q, Liu X, Zhou W, Wang L, Zheng X, Wang X, Wu S. Long sleep duration and risk of ischemic
stroke and hemorrhagic stroke: The kailuan prospective study. Scientific reports. 2016;6:33664
62. Kawachi T, Wada K, Nakamura K, Tsuji M, Tamura T, Konishi K, Nagata C. Sleep duration and the
risk of mortality from stroke in japan: The takayama cohort study. Journal of epidemiology / Japan
Epidemiological Association. 2016;26:123-130
63. Helbig AK, Stockl D, Heier M, Ladwig KH, Meisinger C. Symptoms of insomnia and sleep duration
and their association with incident strokes: Findings from the population-based monica/kora augsburg
cohort study. PloS one. 2015;10:e0134480
64. Leng Y, Cappuccio FP, Wainwright NW, Surtees PG, Luben R, Brayne C, Khaw KT. Sleep duration
and risk of fatal and nonfatal stroke: A prospective study and meta-analysis. Neurology. 2015;84:1072-
by guest on September 15, 2017http://jaha.ahajournals.org/Downloaded from

1079
65. Ruiter Petrov ME, Letter AJ, Howard VJ, Kleindorfer D. Self-reported sleep duration in relation to
incident stroke symptoms: Nuances by body mass and race from the regards study. Journal of stroke
and cerebrovascular diseases : the official journal of National Stroke Association. 2014;23:e123-132
66. Pan A, De Silva DA, Yuan JM, Koh WP. Sleep duration and risk of stroke mortality among chinese
adults: Singapore chinese health study. Stroke; a journal of cerebral circulation. 2014;45:1620-1625
67. Chen JC, Brunner RL, Ren H, Wassertheil-Smoller S, Larson JC, Levine DW, Allison M, Naughton
MJ, Stefanick ML. Sleep duration and risk of ischemic stroke in postmenopausal women. Stroke; a
journal of cerebral circulation. 2008;39:3185-3192
68. Tu X, Cai H, Gao YT, Wu X, Ji BT, Yang G, Li H, Zheng W, Shu XO. Sleep duration and its correlates in
middle-aged and elderly chinese women: The shanghai women's health study. Sleep medicine.
2012;13:1138-1145
69. Smagula SF, Koh WP, Wang R, Yuan JM. Chronic disease and lifestyle factors associated with
change in sleep duration among older adults in the singapore chinese health study. Journal of sleep
research. 2016;25:57-61
70. Stamatakis E, Rogers K, Ding D, Berrigan D, Chau J, Hamer M, Bauman A. All-cause mortality
effects of replacing sedentary time with physical activity and sleeping using an isotemporal
substitution model: A prospective study of 201,129 mid-aged and older adults. International Journal
of Behavioral Nutrition and Physical Activity. 2015;12
71. Azevedo Da Silva M, Singh-Manoux A, Shipley MJ, Vahtera J, Brunner EJ, Ferrie JE, Kivimaki M,
Nabi H. Sleep duration and sleep disturbances partly explain the association between depressive
symptoms and cardiovascular mortality: The whitehall ii cohort study. Journal of sleep research.
2014;23:94-97
72. Werle MH, Moriguchi E, Fuchs SC, Bruscato NM, de Carli W, Fuchs FD. Risk factors for
cardiovascular disease in the very elderly: Results of a cohort study in a city in southern brazil.
European journal of cardiovascular prevention and rehabilitation : official journal of the European
Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and
Exercise Physiology. 2011;18:369-377
73. Krueger PM, Saint Onge JM, Chang VW. Race/ethnic differences in adult mortality: The role of
perceived stress and health behaviors. Social science & medicine (1982). 2011;73:1312-1322
74. Kripke DF, Langer RD, Elliott JA, Klauber MR, Rex KM. Mortality related to actigraphic long and
short sleep. Sleep medicine. 2011;12:28-33
75. Branch LG, Jette AM. Personal health practices and mortality among the elderly. American
journal of public health. 1984;74:1126-1129
76. Kripke DF, Simons RN, Garfinkel L, Hammond EC. Short and long sleep and sleeping pills. Is
increased mortality associated? Archives of General Psychiatry. 1979;36:103-116
77. Hammond EC. Some preliminary findings on physical complaints from a prospective study of
1,064,004 men and women. American journal of public health and the nation's health. 1964;54:11-23
78. Ford ES. Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled
cohort risk equations among us adults. Journal of the American Heart Association. 2014;3:e001454
79. Benito-Leon J, Louis ED, Villarejo-Galende A, Romero JP, Bermejo-Pareja F. Long sleep duration in
elders without dementia increases risk of dementia mortality (nedices). Neurology. 2014;83:1530-
1537
80. Eguchi K, Hoshide S, Ishikawa S, Shimada K, Kario K. Short sleep duration and type 2 diabetes
by guest on September 15, 2017http://jaha.ahajournals.org/Downloaded from

enhance the risk of cardiovascular events in hypertensive patients. Diabetes research and clinical
practice. 2012;98:518-523
81. Eguchi E, Iso H, Tanabe N, Yatsuya H, Tamakoshi A. Is the association between healthy lifestyle
behaviors and cardiovascular mortality modified by overweight status? The japan collaborative cohort
study. Preventive medicine. 2014;62:142-147
82. von Sarnowski B, Putaala J, Grittner U, Gaertner B, Schminke U, Curtze S, Huber R, Tanislav C,
Lichy C, Demarin V, Basic-Kes V, Ringelstein EB, Neumann-Haefelin T, Enzinger C, Fazekas F, Rothwell
PM, Dichgans M, Jungehulsing GJ, Heuschmann PU, Kaps M, Norrving B, Rolfs A, Kessler C, Tatlisumak
T. Lifestyle risk factors for ischemic stroke and transient ischemic attack in young adults in the stroke in
young fabry patients study. Stroke; a journal of cerebral circulation. 2013;44:119-125
83. Vgontzas AN, Liao D, Pejovic S, Calhoun S, Karataraki M, Basta M, Fernández-Mendoza J, Bixler
EO. Insomnia with short sleep duration and mortality: The penn state cohort. Sleep. 2010;33:1159-
1164
84. Huppert FA, Whittington JE. Symptoms of psychological distress predict 7-year mortality.
Psychological medicine. 1995;25:1073-1086
85. Jackowska M, Steptoe A. Sleep and future cardiovascular risk: Prospective analysis from the
english longitudinal study of ageing. Sleep medicine. 2015;16:768-774
86. Breslow L, Enstrom JE. Persistence of health habits and their relationship to mortality. Preventive
medicine. 1980;9:469-483
87. Smagula SF, Stone KL, Redline S, Ancoli-Israel S, Barrett-Connor E, Lane NE, Orwoll ES, Cauley JA.
Actigraphy- and polysomnography-measured sleep disturbances, inflammation, and mortality among
older men. Psychosomatic medicine. 2016;78:686-696
88. Zawisza K, Tobiasz-Adamczyk B, Galas A, Brzyska M. Sleep duration and mortality among older
adults in a 22-year follow-up study: An analysis of possible effect modifiers. European journal of
ageing. 2015;12:119-129
89. Ding D, Rogers K, van der Ploeg H, Stamatakis E, Bauman AE. Traditional and emerging lifestyle
risk behaviors and all-cause mortality in middle-aged and older adults: Evidence from a large
population-based australian cohort. PLoS medicine. 2015;12:e1001917
90. Li Y, Sato Y, Yamaguchi N. Lifestyle factors as predictors of general cardiovascular disease: Use for
early self-screening. Asia-Pacific journal of public health / Asia-Pacific Academic Consortium for Public
Health. 2014;26:414-424
91. Lee JS, Auyeung TW, Leung J, Chan D, Kwok T, Woo J, Wing YK. Long sleep duration is associated
with higher mortality in older people independent of frailty: A 5-year cohort study. Journal of the
American Medical Directors Association. 2014;15:649-654
92. Hoevenaar-Blom MP, Spijkerman AM, Kromhout D, Verschuren WM. Sufficient sleep duration
contributes to lower cardiovascular disease risk in addition to four traditional lifestyle factors: The
morgen study. European journal of preventive cardiology. 2014;21:1367-1375
93. Piccolo RS, Yang M, Bliwise DL, Yaggi HK, Araujo AB. Racial and socioeconomic disparities in sleep
and chronic disease: Results of a longitudinal investigation. Ethnicity & disease. 2013;23:499-507
94. Martínez-Gómez D, Guallar-Castillón P, León-Muñoz LM, López-García E, Rodríguez-Artalejo F.
Combined impact of traditional and non-traditional health behaviors on mortality: A national
prospective cohort study in spanish older adults. BMC medicine. 2013;11
95. Eguchi E, Iso H, Tanabe N, Wada Y, Yatsuya H, Kikuchi S, Inaba Y, Tamakoshi A. Healthy lifestyle
behaviours and cardiovascular mortality among japanese men and women: The japan collaborative
by guest on September 15, 2017http://jaha.ahajournals.org/Downloaded from

cohort study. European heart journal. 2012;33:467-477
96. Dew MA, Hoch CC, Buysse DJ, Monk TH, Begley AE, Houck PR, Hall M, Kupfer DJ, Reynolds CF.
Healthy older adults’ sleep predicts all-cause mortality at 4 to 19 years of follow-up. Psychosomatic
medicine. 2003;65:63-73
97. Kaplan GA, Seeman TE, Cohen RD, Knudsen LP, Guralnik J. Mortality among the elderly in the
alameda county study: Behavioral and demographic risk factors. American journal of public health.
1987;77:307-312
98. Wingard DL, Berkman LF, Brand RJ. A multivariate analysis of health-related practices: A nine-year
mortality follow-up of the alameda county study. American journal of epidemiology. 1982;116:765-
775
99. Riemann D, Baglioni C, Spiegelhalder K. [lack of sleep and insomnia. Impact on somatic and
mental health]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2011;54:1296-
1302
100. Seki N. [relationships between walking hours, sleeping hours, meaningfulness of life (ikigai) and
mortality in the elderly: Prospective cohort study]. Nihon eiseigaku zasshi. Japanese journal of
hygiene. 2001;56:535-540
101. Tamakoshi A, Ohno Y. Self-reported sleep duration as a predictor of all-cause mortality: Results
from the jacc study, japan. Sleep. 2004;27:51-54
102. Ferrie JE, Shipley MJ, Cappuccio FP, Brunner E, Miller MA, Kumari M, Marmot MG. A prospective
study of change in sleep duration: Associations with mortality in the whitehall ii cohort. Sleep.
2007;30:1659-1666
by guest on September 15, 2017http://jaha.ahajournals.org/Downloaded from

Kaifeng Yu, Wei Bao, Wei Yang, Xiaoyi Chen and Liegang Liu
Jiawei Yin, Xiaoling Jin, Zhilei Shan, Shuzhen Li, Hao Huang, Peiyun Li, Xiaobo Peng, Zhao Peng,
Analysis of Prospective Cohort Studies−Response Meta−Systematic Review and Dose Cause Mortality and Cardiovascular Events: A−Relationship of Sleep Duration With All
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